The Straits Times
07Feb2021: 5 doses of
Covid-19 vaccine given to S'pore National Eye Centre worker due to human error
It
was reported that a staff member at the Singapore National Eye Centre (SNEC) has
been mistakenly given the equivalent of five doses of the Pfizer-BioNTech
Covid-19 vaccine. This occurred during a vaccination exercise on Jan 14, and
was due to human error resulting from a lapse in communication among members of
the vaccination team, said SNEC on Saturday (Feb 6). It said it has been
following up closely with the staff member, who remains well.
SNEC
said the worker in charge of diluting the vaccine had been called away to
attend to other matters before it was done.
A
second staff member had then mistaken the undiluted dose in the vial to be ready
for administering. The error was discovered within minutes after the
vaccination.
As
a safety measure, the vaccination exercise at SNEC was stopped immediately upon
detection of the error, and the rest of the staff were vaccinated at SGH.
The
centre is not involved in the vaccination of other groups.
The
SNEC has apologised to the affected staff member and the worker’s family, said
Professor Wong Tien Yin, the medical director of the centre. “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,” he added.
He
said that the centre has
done a thorough review of its internal processes, and taken steps to
tighten them so that such lapses do not occur again.
This
isn’t the first time blunders made by public hospitals and health institutions like
this have been reported. Many, I believe went un-reported.
This
event is just another example to illustrate the importance of managing change
in the workplaces and organizations. Deploying an reactive approach towards
managing change could be fatal at times. Some may question: shouldn’t ‘a thorough
review of internal processes’ be conducted prior to the implementation of change?
The short answer is probably YES! Again, this depends on the competencies and
skills of the change management team and the change approach or model deployed
in this hospital.
There
are many change management models designed by many authors. Some models are
relatively complex to understand without an in-depth knowledge of its benefits,
pitfalls and implementation difficulties. The simplest change management model
is the 5M Approach (copyrighted) as depicted here. This change management model
can be used to suit every situation and in various change categories:
financial, operations, quality, environmental, workplace safety and health
aspect.
For
more information and training on the use of this change management model,
kindly contact us.