After En Chu Kong Hospital in New Taipei City on Monday last week administered doses of the Pfizer-BioNTech vaccine without diluting it as required, the Central Epidemic Command Center fined the hospital and suspended its right to administer vaccines.
The New Taipei City Department of Health is to review the vaccination procedure and discuss whether the 25 people who received wrong doses need an additional shot.
Although 11 of the 13 recipients who agreed to being hospitalized for observation have been discharged and things are now under control, members of the public are beginning to ask who is accountable for the mistake.
Studies have shown that medication errors are the most common medical error, occurring 3.7 to 16.6 percent of the time. Mistakes can occur at any stage of the process.
The hospital told a news conference that the mistake was made due to negligence during the handover between the pharmacist and the nurse.
Human error being the cause of the incident inevitably leads the public to call for the individuals involved to be held responsible.
However, to prevent similar incidents from happening and to ensure safety with regards to medication, the systemic factors leading to errors by pharmacists and nurses should be reviewed.
Medical staff have been working hard on the front lines to fight the COVID-19 pandemic and protect the public. Since the introduction of COVID-19 vaccines in Taiwan, in addition to administering the shots at their hospitals or clinics, pharmacists and nurses must also support large-scale vaccination stations set up in local communities.
However, there are different COVID-19 vaccine brands, and people receiving the shots are categorized in many groups.
All these factors cause problems that can easily lead to systemic medication errors.
Each time a nurse is assigned a different vaccine, they have to handle it differently. Each vaccine has its own storage requirements and pre-administration procedures.
The Pfizer-BioNTech vaccine is perhaps the one with the most stringent storage conditions, and the pre-administration procedure has 10 separate steps.
To fight the pandemic, most nurses are doing more work than what is normally required of them. This means that they might not be familiar with the work environment or procedures they are assigned to, or even the team members they are working with. These factors increase the possibility of systemic error.
Medical errors are an important issue everywhere in the world, and making mistakes is human nature. As a large number of people are getting vaccinated, a certain number of errors will inevitably occur.
After the incident in New Taipei City, the hospital immediately initiated a procedure to handle the situation and made a public apology.
The city’s health department launched an investigation and is aiming to improve vaccination procedures, as well as monitoring and auditing mechanisms.
Regardless of whether the error caused any harm, the focus should be on how to prevent a similar incident from happening again. To ensure safe administration of vaccines, those who made the mistake should not be personally held accountable.
Medical staff are human beings, not gods. Please do not thank them publicly while exposing them to a witch hunt.
Chen Ching-min is a professor at National Cheng Kung University’s Department of Nursing.
Translated by Lin Lee-kai
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