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Singapore National Eye Centre Vaccination Incident

Name and Constituency of Member of Parliament
Ms Ng Ling Ling 
MP for Ang Mo Kio GRC 

Question No. 712
To ask 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.

Name and Constituency of Member of Parliament
Mr Yip Hon Weng
MP for Yio Chu Kang

Question No. 713
To ask 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.

Name and Constituency of Member of Parliament
Mr Gerald Giam Yean Song
MP for Aljunied GRC 

Question No. 715
To ask 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 multitask so as to avoid human errors of the type which occurred in the Singapore National Eye Centre.

Oral Answer
1.     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 MOH have also followed up closely with the affected staff at SNEC, who remains well with no adverse reaction nor side effects. 

2.     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. 

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

4.     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.  

5.     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. 

6.     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. 

7.     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.

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