NHS apologises over vaccine fridge errors that left hundreds potentially exposed
NHS Shetland has again apologised after hundreds of people – including children – needed to be re-vaccinated because medication had been stored at incorrect temperatures.
Problems emerged in February when a routine check raised concerns about the fridge temperatures at Lerwick Health Centre.
A review identified that “for short periods” since 1st August 2017 some vaccines had been stored above the recommended maximum temperature. A health board probe established 171 children and teenagers and 91 adults’ vaccines had potentially been affected.
Amid concerns some vaccines may not provide the required level of immunity those patients were contacted and advised to get revaccinated at dedicated clinics.
Following a health board review of “processes and practice” NHS Shetland chief executive Ralph Roberts has again apologised to those affected.
Speaking after a meeting of the board’s Clinical Care and Professional Governance Committee on Tuesday he said patient welfare was the priority and he was sorry that there had been any concern raised for patients and their families
He also emphasised that immunisation plays a key role in ensuring long-term protection for individuals against infection and encouraged anyone still to undergo revaccination to seriously consider this.
Mr Roberts said as a result of the two-part review a number of safeguards had been put in place to prevent a repeat.
Committee members were said to be complimentary about the professional way in which the incident had been handled and the work that has been done to learn lessons and put in place corrective action.
The action taken includes adding data loggers to monitor fridge temperature, giving staff additional training and introducing a professional leadership structure.
More details in Friday’s Shetland Times.
Christopher Johnston
“The actions taken include … introducing a professional leadership structure.”
Was there no prior leadership structure? Or was there a prior unprofessional leadership structure? Does this prior condition exist elsewhere in NHS Shetland?
It seems to me that NHS Shetland owes its clients some answers,
Paul Smith
Having worked for the health board, I have to agree with Christopher, there is no structure for leadership, however these is a strong culture of empire building by senior management, which makes clinical practice unsafe. This is prevalent certainly around primary care.
Sandy Lunoe
It is worrying that many received the vaccines twice because of possible increase in side effects.
STORAGE CONDITIONS FOR VACCINES
Adequate storage temperature is imperative. They should normally be stored continuously between +2 and +8 C. At higher temperatures for any amount of time the ingredients may interact, decompose, form aggregates and/or precipitate. Microbial growth may take place. The vaccines may be detrimental to health.
Maintaining optimal temperature is not simply a matter of reading a thermometer. These may present a rise or fall in temperature whilst being read, it is impossible to read the highest/lowest temperature reached, they may not show the temperature in or near the actual vaccine vials – and they are often inaccurate.
Maximum-minimum thermometers show the highest/lowest temperatures reached, but not the length of time the temperatures have been maintained.
Thermal feelers in refrigerators connected to graph-drawing systems which register and draw temperature variations continuously may be used, but are expensive.
The temperature in a refrigerator varies according to whether it is measured high, low, at the back or near the door. When many units are placed in the refrigerator at the same time the temperature may only become stable after some hours.
Steve Hinks
In 192821, Bundaberg children were immunised with diphtheria toxin-antitoxin that was later found to be contaminated with staphylococcus aureus. Within 24 hours, 18 of the children fell seriously ill and, despite medical intervention, 12 died within 48 hours.
In conclusion “it was no one’s fault. It was because of the lack of refrigeration and the storage that the serum was off – it was poisonous”. Three brothers from one family all died.
See: https://www.pressreader.com/australia/newsmail/20170328/281505046051191
Are we sure that it is only NHS Scotland that has been caught out for incorrect storage of vaccines? I don’t think so. I
Shuard Manson
I have been vaccinated against Polio, Smallpox, measles, flu and Lockjaw. At least two of them don’t exist anymore. Should I wear a foil hat?
Mr ian Tinkler
Sadly polio has reemerged!! smallpox is in germ labs and not too hard to release, either by accident or design as a biological attack. Flu and Tetanus always present so keep your foil hat on Shuard you never know whats around the corner!!!
Shuard Manson
My point was vaccination is better than no vaccination. I don’t think that requires a foil hat. I’m sure I will soon stand corrected
Shuard Manson
I only read the first half of your comment Ian. I didn’t see your humour and fair point. I regret my reply. Winding bacofoil around my head and weeping.
Wayne Conroy
Just take the advice of those genius anti-vaxxers and rub some of those essential oils on your head Shuard… you’ll be sorted in no time!
Mr ian Tinkler
Awful fact, ISIS and Al-Qaeda refusing polio vaccinations as regard vacination as a Western plot to cause infertility!! From Pakistan, the virus could arrive in the UK on any traveler at any time. If Russia can introduce Novichok into the Uk, any lunatic State could likewise introduce Smallpox!!! Dangerous times ahead!!!
Ali Inkster
Any lunatic state? Or just any lunatic walking across the open borders your so keen on
Mr ian Tinkler
No one walks very far incubating Smallpox or Polio, Ali! It would be commercial flights and airport hubs where these diseases would be spread. Just thought I should initiate the blind ignorant and prejudiced. Refugees would not be the problem! Rather like Ebola in the UK, health workers could well be the carriers!!
Ali Inkster
Forgive my obvious ignorance I always thought disease managed to spread before air travel existed, I stand corrected by your superior intellect and understanding of history.
David Spence
It would be interesting to know what the Council’s action would be in regard to preventing any dangerous disease entering Shetland?
What procedures would they have in place in terms of boats and aircraft (main life line boat, fishing boats, yachts, airline travel (either Scatsta or Sumburgh or inter-island flights)? How would quarantine procedures affect smaller island communities or if one of the islands had an infected population (whether 1 or many persons)? How would you screen people coming into Shetland or the islands?
Would Shetland become more isolated? In some respect, this would be, overall, advantageous due to Shetlands isolation and remoteness in terms of controlling or stopping any disease from arriving on the islands or being spread further afield?
How would you monitor those infected or carriers of the disease and would they be moved to more remote islands to prevent further contamination or restrict movement of the disease?
It is a daunting thought, but one which, I presume, has been looked into, regardless of how remote this scenario may be?