COVID-19 vaccine protocols in place, but doesn’t eliminate ‘human error’

Published: Dec. 29, 2020 at 4:52 PM CST
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GREEN BAY, Wis. (WBAY) - As millions wait their turn to get the COVID-19 vaccine in Wisconsin, news of hundreds of doses spoiled due to human error is not an update anyone wanted to hear.

Earlier this week, Aurora Medical Center in Grafton had to throw away 500 Moderna vaccines because someone left them out of the refrigerator overnight.

All vaccination sites are required to have continuous monitoring data logs. According to the 60-page Department of Health Services ‘COVID-19 Vaccination Plan’ all off-site clinics must have ‘temperature monitors that can alarm if the temperature exceeds vaccine storage limits’. However, that doesn’t account for human error.

“We can put all those processes in place, but sometimes when people are multitasking, you leave things out,” said Laura Alar, Bellin Health’s Director of Pharmacy. “It’s like when you have coffee in the morning and put your half and half aside and sometimes you come home at the end of the day and it’s still sitting there; you can’t use it. You know it could be contaminated. So it’s the same situation.”

If vaccines are left un-refrigerated for an extended period, they must be thrown away.

“You cannot refreeze. It would be like buying a meat and then trying to refreeze it, you cannot guarantee the integrity of the product once it’s thawed,” said Alar.

Alar said Bellin Health has monitoring protocols in place.

“We actually have a workflow with timelines, in terms of transferring product and having three minutes to do that to get it into a cooler for the transport process, and here at Bellin we work together between departments to coordinate those transfers of product,” said Alar. “We’re fortunate we have a tool in our electronic system to track that inventory…. We use an epic roll inventory module and we enter those doses, but again, that does not prevent inadvertent oversights like setting a box of vaccines out.”

Although no one wants any dose to go unused, Alar said people have to remember this is new and very technical.

“I think we have to be patient and we’re learning and then there are two different vaccine types. And there are going to be other prototypes coming out that have different refrigeration or freezer and storage considerations. So I think we could expect that,” said Alar.

Any vaccine wastage or spoilage ‘greater than 5 doses’ has to be reported to the state and CDC.

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