COVID-19 vaccine error highlights risks but Prime Minister Scott Morrison says the system will improve

A “serious error” that saw two Queensland aged care residents injected with the wrong dose of the COVID-19 vaccine has raised questions about the rollout.

The rollout of Australia’s much-anticipated vaccination program was undermined this week by a “serious error” that saw two Queensland aged care residents given around four times the recommended dose.

The mistake has raised concerns it will erode confidence in the Federal Government’s ambitious rollout program that aims to vaccinate all adult Australians against the coronavirus by October.

But one expert says that human errors are bound to happen in such a large-scale program.

“The key now is what action we’re going to take to minimise the risk of this happening again,” Associate Professor Nigel Crawford of Murdoch Children’s Research Institute wrote in a piece for The Conversation.

Prof Crawford noted that clinicians in Australia were not used to delivering vaccines from multi-dose vials, “meaning there’s a greater risk of error”.

However, given the publicity around what has been described by authorities as a “serious error”, Health Minister Greg Hunt told reporters there would not be a medical professional in the country who was not now “acutely aware” the vaccines were delivered in multi-dose vials.

“What we’ll see is that the entire country is aware,” he said on Wednesday.

Deputy chief medical officer Professor Michael Kidd also noted that similar high doses, or even higher doses of the Pfizer vaccine were given to volunteers during clinical trials, without significant side effects being reported.

“There have also been similar incidents of incorrect administration of higher doses of the vaccine reported in other countries as they have been rolling out their vaccines, including in Germany and the United Kingdom,” Prof Kidd said.

Both of the aged care residents who were given the wrong dose in Queensland have not experienced any side effects so far.

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Australia’s vaccination program got underway this week. Picture: Tara Croser

HOW DID THE MISTAKE HAPPEN?

The Pfizer vaccine is delivered in a vial that contains five or potentially six doses, Prof Crawford explains.

This means that staff need to draw out one individual dose from the vial. This is different from most other vaccines, which come in single-dose vials.

“Multi-dose vials are useful in a pandemic situation,” he noted. “They allow manufacturers to distribute more vaccine, more easily and rapidly around the world.”

Mistakes can happen if the clinicians are not careful with how much they extract, or they haven’t understood the education and training provided.

In the case of the doctor who made the error at Holy Spirit Home in Carseldine on Wednesday, it later emerged they had not done the compulsory online training required. A nurse noticed the doctor’s mistake and intervened.

Healthcare Australia (HCA), which is one of the private contractors hired by the Federal Government to help with the vaccine rollout in aged care facilities, initially said the doctor had completed the training and that it had cited successful Certificates of Completion for all its clinicians.

But HCA later admitted it had not seen the certificate for the doctor and they had not in fact, completed the course.

Mr Hunt said false information was given to the Health Department despite “repeated interrogation” and was eventually uncovered when the department demanded “visual proof”.

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There are several doses of the vaccine in one vial. Picture: Emma Brasier

WHAT IS BEING DONE ABOUT IT?

Mr Hunt said HCA has had the “book thrown at it” after the incident.

The doctor involved has been stood down from the vaccination program and the Health Department have double checked that all other doctors hired by HCA had completed the compulsory online training.

HCA’s chief executive officer Jason Cartwright has also been stood aside and the company has been put on notice of potential termination for any further significant breaches.

The company has installed Australia’s former chief nursing and midwifery officer, Debra Thoms, to work with the company and review its staffing arrangements, at the request of the Commonwealth.

The incident has been reported to the Office of the Health Ombudsman in Queensland, which will decide whether to refer the incident to the Australian Health Practitioner Regulation Agency (AHPRA).

Queensland Premier Annastacia Palaszczuk has also expressed concern about the incident and said she would be writing to Prime Minister Scott Morrison, asking him to convene national cabinet as soon as possible.

“I want to know what training is provided to the people the Federal Government is employing to administer the vaccines in our aged care facilities,” she said.

The Federal Government is responsible for aged care in Australia and is overseeing the rollout of the vaccine to these facilities across Australia.

Meanwhile, states and territories are running a separate program through 16 Pfizer hubs to vaccinate frontline workers including those in hotel quarantine, healthcare and border control. They are also vaccinating elderly Australians living in state-run facilities.

Prof Crawford said the incident should prompt authorities to check that everyone administering vaccines had completed the required training and this should be documented via their AHPRA registration number where applicable.

Australia should also look at how it reports these sorts of errors as generally vaccine safety surveillance focused mainly on whether patients experienced an adverse event.

“In the context of global vaccinations against COVID-19, multi-dose vials are the only way forward,” Prof Crawford said.

“The AstraZeneca vaccine will also come in multi-dose vials. So this is something we must do the best we can to get right.”

‘WE WILL IMPROVE’

Prime Minister Scott Morrison appeared before reporters on Friday to reassure Australians that the vaccination program would continue to improve, as reports also emerged of delays and slower-than-anticipated distribution in some states.

He said 90 aged care facilities had already had their residents vaccinated.

“We’re in day four of a nine-month program,” he said.

Mr Morrison said families should not be anxious about logistic issues in the early phases as “they’ll be quickly addressed”.

“They’ll soon be followed up and the vaccinations will rise,” he said.

“People are working hard to deliver on the ground. This is mobilising quite a national effort.

“As we go from day to day, the lessons of each day will only make the system better, more improved, but at all times, safety is the paramount issue.”

The government expects 60,000 doses of the Pfizer vaccine will have been administered by the end of February, with 30,000 doses going to Commonwealth aged care facilities.

So far 142,000 doses have arrived in Australia with the government initially releasing 80,000 doses for use. About 62,000 doses will be held back for second doses in case there are delays or other issues with further shipments.

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