Update on Incident where Singapore National Eye Centre Staff was Given Wrong Dosage of COVID-19 Vaccine

3 Ms Ng Ling Ling asked the Minister for Health following the wrong dosage of the COVID-19 vaccine for one staff at the Singapore National Eye Centre, how has the standard operating procedure been improved to ensure that such a mistake will not recur in other vaccination sites.

4 Mr Yip Hon Weng asked the Minister for Health with regard to the recent vaccination overdose incident in Singapore National Eye Centre (a) why was there no dedicated staff to handle this critical operation and no formal briefing with notes if a handover was necessary; (b) whether there is a standard operating procedure (SOP) across institutions to handle vaccine preparation; and (c) how will the SOP be enhanced to prevent a recurrence.

5 Mr Gerald Giam Yean Song asked the Minister for Health how do public healthcare institutions manage the workload of medical workers to ensure that they are not overworked and made to excessively multi-task so as to avoid human errors of the type which occurred in the Singapore National Eye Centre.

The Senior Minister of State for Health (Dr Janil Puthucheary) (for the Minister for Health): Mr Speaker, may I have your permission to take Question Nos 3, 4 and 5 together, please?

Mr Speaker: Yes, please.

Dr Janil Puthucheary: Sir, during the COVID-19 vaccination exercise for staff at the Singapore National Eye Centre (SNEC) on 14 January 2021, a member of staff was given five doses of the Pfizer-BioNTech COVID-19 vaccine in one injection. The error was discovered within minutes. SNEC and the Ministry of Health (MOH) have followed up closely with the affected staff member, who remains well with no adverse reaction nor any side effects.

MOH and SNEC have identified that the error was due to a lapse in communication among the vaccination team. They had been preparing and administering the vaccinations at that time. The staff in charge of diluting the vaccine had been called away to attend to other matters during the preparation of the vaccine before the dilution of the doses in that particular vial had been carried out. A second staff member had mistaken the undiluted doses in that vial to be ready for administration.

Following this incident, as a safety measure, the vaccination exercise at SNEC was immediately stopped. Subsequent vaccinations for staff members were continued at the Singapore General Hospital. SNEC is not involved in Singapore’s vaccination exercises for any other groups.

Medical protocols are in place at all COVID-19 vaccination sites to ensure the safety of vaccinated individuals and to provide guidance on the management of the vaccination process. Clear, written instructions on the preparation and administration of the vaccine are used. There is a designated and segregated area for the preparation and administration of the vaccines. There must be clear labelling to differentiate diluted and undiluted vaccine vials. These instructions are disseminated to and used as training materials for the staff involved in the vaccination process. To ensure that such lapses do not occur again, we have instructed vaccination providers to adhere strictly to the protocols. All vaccination providers must also undergo training to familiarise themselves with these guidelines, protocols and operational workflow prior to the commencement of their vaccination operations. MOH also conducts audits periodically to ensure that safety standards are adhered to.

To ensure that each staff member in the vaccination process is assigned a manageable workload, there are specific stations within the vaccination sites for registration, screening, vaccination and monitoring. There are clearly defined roles undertaken by staff across the stations. Staff should leave their positions only once their immediate task has been completed. Should there be a need to step away, there must be proper documentation and handing over of roles and duties to other staff members.

The public healthcare institutions (PHIs) have planned rostered breaks and staff rotations so that staff have sufficient rest during and between their shifts. The PHIs will also continue to train and hire more healthcare professionals, so that there will be adequate staffing to cater for these work-rest cycles and meet service demands.

I would like to reassure Members of this House that MOH continues to place the utmost importance on the safety of our staff and patients in the vaccination process.

Mr Gerald Giam Yean Song (Aljunied): I thank the Senior Minister of State for the answer. I have two supplementary questions. Should medical workers feel over-worked or over-stretched, what recourse and remedies are available to them and how will they be assured that there will be no penalty on their performance assessments?

Secondly, studies have shown that it is important for hospital managers to carry out management practices that promote job control, in order to reduce burn-out risks. Job control enables workers to make decisions regarding their work and gives them more autonomy at work. Is promoting greater job control something that the hospitals are looking into?

Dr Janil Puthucheary: Mr Speaker, I thank Mr Giam for the questions. If members of staff at the vaccination sites are over-worked or over-stretched, they are not alone. There are staff members who are not assigned to a given station, who are available to relieve them in place and there are other staff members who are supernumerary to a given station, with a specific role of roving around and watching for incidents or the need to step in and assist. There is also a professional domain supervising process that exists, whether you are non-clinical staff or clinical staff, whether you are nursing or medical.

These are part of the practice of clinical medicine. These standard operating procedures, these are practices extended into all the vaccination sites to deliver these crisis vaccination operations.

When it comes to the issue of autonomy and job control, in delivering these COVID-19 vaccinations as a national exercise to deal with the crisis of a pandemic, we have sub-divided the various steps into very specific tasks so that we can ensure safety, supervise the process as well as administer the vaccines to as much of our population as are going to take it up. So, there is not a lot of opportunity for autonomy and flexibility in terms of job roles, job re-creation or job re-design. If Mr Giam is interested in these processes outside of the COVID-19 vaccination operations which is what he filed the question for, I would be happy to have a larger discussion on this matter.

Ms Ng Ling Ling (Ang Mo Kio): Mr Speaker, I thank Dr Janil for the very reassuring answer. I want to first declare that I am a strong advocate for the vaccination programme. Together with the grassroots leaders of Jalan Kayu, we have been actively going out to explain and assure residents to take the vaccine, once their turn comes.

The supplementary question is to assure that the checks and balances are in place, that the safety is there for the vaccination implementation. My question, for the MOH onsite audits, how frequent would these be and would these cover all centres, because there are many vaccination centres that have been rolled out in speed by private medical groups contracted by MOH, and would these also cover the PHIs and the PHPCs?

Dr Janil Puthucheary: Sir, I would like to thank the Member for the question. The vaccination centres, the places where vaccination for COVID-19 is being done, vary quite significantly, both in terms of the locale and the size, the nature of the space. And so, the matters to be audited are going to be different. But some of the fundamentals with respect to skill sets, the equipment, the fundamental processes and most especially, the safety of the patient are not going to change.

So, the frequency and the specifics of the audits will very much depend on which sites we are talking about, what were the previous findings the last time we engaged with them and what we believe are the areas of risks. But we are paying very close attention to all of these and the personnel at the sites, have very clearly at the top of their mind, the safety of the process. And I am reassured by this when I go and visit them, and I have visited a number of them, the attention to detail is quite significant; they are making sure that they want to keep the process as safe as possible for Singaporeans.

So, the nature of the audits, the details that the Member is asking, will vary quite significantly, so I do not have a clean or clear answer. But, indeed, all the sites will be engaged in that process with MOH and our vaccine operations group.

Mr Speaker: Mr Yip Hon Weng.

Mr Yip Hon Weng (Yio Chu Kang): Mr Speaker, Sir, I thank the Senior Minister of State for his reply. My supplementary question is whether the authorities will continue to follow up with the affected employee for long-term side effects and whether the employee will continue to receive care for long-term health problems if the employee leaves the service.

Dr Janil Puthucheary: Mr Speaker, I thank the Member for the question. Certainly, the affected staff member will have healthcare and will be followed up quite closely. But, I would like to reassure that there were no adverse effects, no side effects that were detected, despite what is obviously an error. The nature of adverse effects and side effects from vaccines is that they are present within hours to days usually, after a vaccination. We are quite assured by the health and comfort, and the status of the staff member affected. But we will continue to pay close attention and stay in close touch with the staff.