Overdose doctor had not completed vaccine training
The doctor who gave two elderly Queensland nursing home patients a high dose of COVID-19 vaccine had not completed vaccination training.
Despite earlier telling the Parliament the contrary, Health Minister Greg Hunt said he had new advice the doctor who gave the wrong dose had not completed the training as required.
"This is being investigated," he said.
He said Health Care Australia had now advised that the training had not been completed, despite earlier advice that there were copies of a certificate of completion for the training.
"This doctor has not been involved in the vaccine rollout in any other facility," Mr Hunt said.
"I've advised the Department to take action against both the doctor and the company."
Earlier Mr Hunt apologied to the families involved and he told Parliament the deputy chief medical officer had conducted an investigation and the preliminary report showed the doctor was fully registered with the Australian Health Practitioner Regulation Agency (AHPRA), had met all credentials and completed the full training module.
"That training module involves ensuring that dose administration is carried out, that all stages are carried out, the proper techniques for drawing up doses, the supervisory roles," Mr Hunt said.
"All elements of the training, which could have been done and could have been required were put in place."
He said it was an Australian-trained doctor involved in the incident and all elements of the training had been carried out.
"The advice that we have from the Deputy Chief Medical Officer is very simple. The doctor involved did the wrong thing and that is a case of human error, a case of unacceptable human error," Mr Hunt said.
"The relevant body... has been in dialogue with the government today to make sure that all possible steps can and should be taken to ensure this never occurs again.
"We apologise to the families involved."
The report followed reports that the GP who administered the vaccines left the Brisbane nursing home without telling the patients.
It was reportedly left to nursing home staff to inform the 88-year-old man and a 94-year-old woman at the Holy Spirit Nursing Home, Carseldine, that they'd been given four times the standard dose of vaccine.
The GP's mistake was noticed by another Healthcare Australia staff member.
Premier Annastacia Palaszczuk has demanded Scott Morrison hold an urgent National Cabinet meeting to investigate the overdoses.
It's understood the doctor contracted by the Federal Government used the entire vial of the Pfizer vaccine. The doctor has been stood down.
Ms Palaszczuk said the news was concerning and she would be writing to the Prime Minister to ask for more details of the training the private contractors administering the vaccine on behalf of the federal government had received.
"I'm advised the overdosing happened yesterday morning," she said.
"Queensland authorities were advised late last night.
"In fact the Health Minister herself rang me late last night and we convened again this morning at 7am.
"Discovering these details now is simply not good enough."
There are very concerning reports about an incident in an aged care facility in Brisbane.— Annastacia Palaszczuk (@AnnastaciaMP) February 24, 2021
The Federal Government is responsible for the roll-out of the vaccine in aged care and they’re using private contractors to deliver it.
Ms Palaszczuk said she was advised it was only the intervention of a nurse that prevented further overdoses and that the doctor concerned had been stood down.
"None of this is good enough and the federal government must explain itself," she said.
"Today I'll write to the Prime Minister asking for him to convene a National Cabinet as soon as possible.
"I want to know what training is being provided to the people the Federal Government is employing to administer the vaccines in our aged care facilities to give additional confidence.
"I want to know the communications strategies for the next phases of the rollout of the vaccine.
"People need and must have full confidence in these vaccines."
She said the Federal Government must also give regular updates on who they are vaccinating and how many, just as the states were doing.
"It is only through this bipartisan support that we can achieve the full confidence of the Australian public and the Queensland public," she said.
Health Minister Yvette D'Ath said the Commonwealth had already committed to share the findings of its investigation with Queensland authorities.
She said 527 Queensland health workers had received the vaccine so far this week at the Gold Coast University Hospital hub and the Princess Alexandra vaccination hub would come online today.
Federal Health Minister Greg Hunt said there would be an investigation into the incident and whether there was a "serious breach in terms of following the protocol".
"Our advice is that both doses were administered consecutively and, as a consequence of that, the nurse - and we say thank you for her strength of character and alertness - stepped in immediately," he said.
"This is an individual practitioner that's clearly made an error and around the county and you will remember from multiple press conferences, whether it's the flu or other things, during the course of any one year there would be challenges, issues and errors. Ordinarily they wouldn't be focused on."
"I've made the decision that we should address this front up to showcase the safeguards we've put in place."
"We wanted to get on with the vaccination quickly, so we went with a single one size fits all module. It's the same training. There may be a need for us to modify that going forward.
In the meantime, that doctor is not going to be delivering further vaccines for the moment."
St Vincent's Care Services Australia CEO Lincoln Hopper said the GP in question has been reported to an Australian regulatory body.
"St Vincent's Care Services can confirm that a GP, employed by Healthcare Australia, an agency contracted by the Commonwealth to carry out COVID-19 vaccinations administered an incorrect dose of the COVID vaccine to two of its residents on Tuesday," Mr Hopper said.
"The job of administering the vaccine was the role and responsibility of Healthcare Australia."
"The health of the two residents is being closely monitored and no adverse effects have been identified."
Mr Hopper said he was 'really disappointed' with the GP's blunder and thanked the nurse for stepping in.
"I'm glad that person spoke up and intervened in that situation and that is clearly part of the failsafe measures and should be the case, good on her," Mr Hopper said
"The families are doing okay in the context of the situation but certainly we need to continue to monitor the residents and we are not out of the woods in that sense," Mr Hopper said.
"I'm really disappointed with what has happened, really distressed that our residents were put in harms way and really frustrated because we've all been longing for this moment."
Mr Hopper said vaccinations are underway again today with 95 per cent of the residents having said yes to the vaccine.
"Our confidence in the vaccine hasn't been rocked by this at all, we are just wanting to reassure the process doesn't allow anything like this to happen again," Mr Hopper said.
"St Vincent's intends to report the GP to the Australian Health Practitioner Regulation Agency for the error."
Mr Hopper said before they allow further vaccinations to continue at any of their sites, any provider will need to confirm the training and expertise of the clinicians, so " an incident like this doesn't happen again.
"This incident is extremely concerning. It's caused us to question whether some of the clinicians given the job of administering the vaccine have received the appropriate training," he said.
"Certainly, health authorities and contracted vaccination providers should be re-emphasising to their teams the need to exercise greater care so an error like this doesn't happen again."
"Yesterday was very distressing to us, to our residents and to their families."
Infectious disease physician and microbiologist Paul Griffin described the overdosing incident as "really disappointing" but said it was unlikely to cause serious complications for the elderly people involved.
"There's a wide safety margin in terms of the doses that are used and so the likely eventuality is that these people won't have any ill effects," Associate Professor Griffin said.
"In terms of it being likely to be a problem, the short answer there is no.
"In the animal studies before we even progress to clinical trials, we often test 50 or 100 times these sort of doses.
"We don't want this to undermine people's confidence in the vaccine."
Prof Griffin said he expected the incident to be "very carefully reviewed" and processes implemented to reduce the possibility of an overdose happening again.
"I think the actual risk here is exceedingly low but I think the perceived risk and the unfortunate scepticism that might be fuelled by this is potentially significant," he said.
"We need to make really sure that we get this right from now on so that everyone can be reassured that they're getting the right dose."
The vaccination process is such a simple process for GPs that the chance of making a mistake is very slim but because it is basic doctoring 101 it is important that a clinic workflow is in place to eliminate distractions, the Queensland chair of the Royal Australian College of General Practitioners told The Courier-Mail.
"GPs will all have been properly trained in administering the COVID-19 vaccine but honestly all GPs know the processes, we have been giving vaccines for decades, there is no need for the public to worry when the AstraZeneca is rolled out in the in the next month," Dr Bruce Willett said.
Practice sessions of the protocol will be put into place in GP clinics just as they were in at The Gold Coast University Hospital.
The incident comes as the second hospital Pfizer vaccine hub in Queensland was launched at the Princess Alexandra Hospital today.
Princess Alexandra Hospital Director of Infection Management Services Dr Geoffrey Playford said safety had been at the forefront of each step in the lead up to the launch.
"Clearly it's the number one priority to make sure that safety for the vaccines occurs," he said.
"We have been well aware of the requirements and how to handle the vaccine, we're well aware that these are multi=-dose vials, we have systems in place and a dedicated team that draws up the individual doses so we don't believe there's any risk of this occurring.
"I couldn't comment on the procedures that the subcontractors have, we are, though, confident that our own processes of safety will be met."
He said the most likely side effect would be minor.
"I don't think anyone knows (how unsafe a higher dosage is), but what we do know from the trials of earlier vaccines, a higher dose is unlikely to lead to any significant problems, perhaps an extra local pain in the injection site but not a significant risk," he said.
"I think that people should be reassured that any deviations from the procedures towards the vaccine are rapidly identified and corrected and I think that process is well and truly underway."
"I think the public should be very confident that the procedures are in place to ensure that safety is the number one concern. Anything that needs to be corrected will be corrected."