GP who gave incorrect COVID-19 vax dose was not trained

syringe vaccine

Pharmacy Guild says the incident reveals that mistakes can occur no matter which profession the immuniser belongs to

A doctor has been stood down from the COVID-19 vaccination program after administering the incorrect dose to two aged care residents on Tuesday.

Federal Health Minister Greg Hunt said a “higher-than-prescribed” dose of the Pfizer vaccine was given to two patients, an 88-year-old man and a 94-year-old woman.

Minister Hunt confirmed that the residents are being closely monitored and so far have shown no adverse effects. He also thanked a nurse on the scene who stepped in and identified the error.

Healthcare Australia, the agency contracted by the Commonwealth to coordinate administration of COVID-19 vaccinations, had initially told Minister Hunt that the doctor had completed the online training required of all providers.

However after receiving “revised advice”, Minister Hunt confirmed in Parliament that the GP had not completed the required training.

St Vincent’s Care Services, which runs the aged care facility in Brisbane, said it intends to report the GP to Ahpra over the error.

“This incident has been very distressing to us, to our residents and to their families,” said Lincoln Hopper, St Vincent’s Care Services CEO.

“It’s also very concerning. It’s caused us to question whether some of the clinicians given the job of administering the vaccine have received the appropriate training.

“Certainly health authorities and contracted vaccination providers should be re-emphasising to their teams the need to exercise greater care to an error like this doesn’t happen again.”

Minister Hunt apologised to the families of the patients and said he has asked the Department of Health “to take action against the company and the doctor for what is a clear breach on both fronts”.

He added that Deputy Chief Medical Officer Michael Kidd would review the incident and make recommendations.

With pharmacists on the receiving end of regular criticism from doctors’ groups about their ability to safely provide vaccines, Pharmacy Guild Victorian branch president Anthony Tassone said the incident reveals that mistakes can occur no matter which profession the immuniser belongs to.

“There has been recent criticism from the RACGP of the nature and length of the mandatory online COVID-19 vaccination training from the Commonwealth being described as a ‘time sink’ and that there should be a shorter course specific for general practitioners to complete,” Mr Tassone told AJP.

“No matter which profession a practitioner belongs to there is not only the risk of errors occurring, but there should be an expectation of the same training to be completed when it comes to the same task or service being provided.

“This is what patients would expect and deserve.

“When it comes to the repeated and obsessive criticism of pharmacist’s ability to adequately deliver vaccination services by doctor’s groups,  one could be tempted to say: ‘those who live in glass houses shouldn’t throw stones’ – but what is most important here is the health and welfare of the patients affected and for all immunisers to reflect on the incident and learn from it for their own practice.”

AMA President, Dr Omar Khorshid, said he was glad to see the two patients concerned appear to be doing well.

“The available evidence from the vaccine rollout overseas suggests there should be no risk to their health,” he said in a comment provided to AJP.

“In a big vaccine rollout like this, including the use of multi-dose vials, there will be isolated instances where mistakes are made.

“It’s important that every healthcare worker involved in the vaccination process has completed the appropriate training,” said Dr Khorshid.

“The systems and processes adopted by providers must minimise the opportunity for mistakes to happen and pick them up quickly when they occur.

“The investigation by the Queensland Deputy CMO and any other appropriate authorities should focus on system improvement and not be about attributing blame.”

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  1. Carole

    I think pharmacists should be involved at all sites at all times

  2. Michael Ortiz

    This is a valuable lesson for for all people giving immunisations.

    If it is in a multiuse vial or an ampoule, then some one needs to check for mistakes like amount of saline added and the dose drawn up into the syringe prior to administration.

    The same issues will occur with the AZ 10 dose ampoule.

    There will be some interesting discussions about what to do with the 10% overage that Manufacturers include to allow for drawing the vaccine up.

    The Pfizer vaccine clearly states that the overage from two vials should not be combined.
    It is unclear whether this statement is medically or financially based.

    I suspect that a black market will emerge in third world countries.

    These mistakes just reinforce the need for training and for administration protocols with inbuilt accuracy checks.

    Looks like the AMA and the RACGP will be on a diet of “humble pie” for a few weeks.

    Given the size of the immunisation program – there will be more mistakes – lets just hope that they are all low risk of harm like these two.

    If you intend to offer COVID19 vaccinations, start planning now.

    Think about running some scenarios in case things go wrong.

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