Singapore National Eye Centre staff received 5 doses of Covid-19 vaccine due to human error

SINGAPORE — An employee at the Singapore National Eye Centre (SNEC) was wrongly administered the equivalent of five doses of the Pfizer-BioNTech Covid-19 vaccine due to a human error, the public healthcare institution said on Saturday (Feb 6). 

The error happened on Jan 14 during a vaccination exercise conducted at SNEC for its staff members.

“The error was discovered within minutes of the vaccination when the staff was resting in a designated area after vaccination,” said SNEC in a press release.

“Senior doctors were alerted immediately and the staff was assessed and found to be well, with no adverse reaction or side effects.”

As a precaution, the affected employee was warded at Singapore General Hospital (SGH) for observation. 

"The staff’s condition remained stable throughout and the staff was discharged two days later. We have been following up closely with the staff, who remains well," said SNEC.

The vaccination exercise at the eye centre was stopped immediately and the rest of its employees were vaccinated at SGH. 

“SNEC is not involved in Singapore’s vaccination exercise for any other groups,” it said.

According to SNEC, investigations showed that it was a human error resulting from a lapse in communication among the vaccination team at the time.

“The staff in charge of diluting the vaccine had been called away to attend to other matters during the preparation of the vaccine, and a second staff member had mistaken the undiluted dose in the vial to be ready for administering,” said SNEC.

The eye centre has done a “thorough review” of its internal processes and has taken steps to ensure that such lapses do not happen again, said SNEC’s medical director Professor Wong Tien Yin, apologising for the incident.

“SNEC takes a very serious view of this incident. The safety of those receiving the vaccination during our staff vaccination exercise is of our utmost priority. We are extremely sorry that this incident happened,” he said.

“We have apologised to the staff concerned and the staff’s family. We will continue to monitor the staff’s health closely and provide the necessary support.”

Singapore started vaccinating its first healthcare worker on Dec 30 in a small-scale test run at the National Centre for Infectious Diseases. 

The vaccination exercise was then rolled out to other healthcare institutions and workers in sectors like aviation and land transport. 

Seniors across Singapore will progressively be offered the vaccine from mid-February. CNA

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