More than 200 people are being contacted to repeat their COVID-19 vaccines because some who attended an immunization clinic in the Niagara region were injected with a saline solution instead of stroke.
Niagara State Public Health said Tuesday that six people were injected with the harmless saline substance on June 16 at a clinic in Port Colborne, Ont.
A recent audit of the day found that six administered doses were not counted and an additional vial of a saline was used. The diluent is intended to be mixed with the Pfizer-BioNTech vaccine concentrate and although it is not harmful, it does not protect against COVID-19.
Dr. Mustafa Hirji, the region’s top doctor, said the health unit was unable to identify the six people who did not receive the vaccine.
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“Unfortunately, with the size of the ongoing clinic and the nature of the provincial vaccination documentation tool, there is no current tracking of individual vaccine doses,” Hirji said.
However, he said public health was able to narrow down a timeline when doses would be administered, identifying 205 people out of 1,148 who were shot that day.
Those individuals were being contacted to book a repeat vaccination after a proper dosing interval. Most will receive a third dose of the COVID-19 vaccine, which the health unit said is safe but offers no additional benefits.
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The health unit said a review was conducted to investigate the error that occurred and new dose tracking and training protocols were introduced to avoid similar situations.
Hirji said the changes include involving more staff members in double-checking the work of others, more detailed documentation in clinics and a plan to find each dose from the refrigerator to the patient who received it.
“The point here is, of course, that there will not be another time, having these dual controls to make sure we stop the error before it happens,” Hirji said. “If unfortunately there is another mistake, we would be able to narrow it closer to just six people.”
Hirji said he does not believe similar situations could have occurred at other Niagara Region clinics based on checks and balances that helped identify the problem by the end of the day at the Port Colborne clinic.
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At least one other such incident has been reported in Ontario since the vaccination campaign began.
Mackenzie Health, which is running vaccination clinics in the York Region, advised the public of a similar mistake in April, saying it contacted six people who had been mistakenly injected with saline instead of a COVID-19 vaccine.
“Our internal quality assurance processes allowed us to identify the issue in a timely manner and contact affected individuals to detect the issue, provide support and test them for antibodies to identify those who needed to re-injected with the vaccine, “Mackenzie Health said in a statement at the time.
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