West Virginia accidentally gives 42 people COVID-19 treatment instead of vaccine

The West Virginia National Guard admitted Thursday that 42 people expecting to receive the Moderna vaccine for COVID-19 were instead accidentally given the Regeneron antibody used to treat infections.

The mistake occurred at a vaccination clinic hosted by staff at the Boone County Health Department, and all of the people who accidentally received the wrong product are being contacted by the department, the National Guard said in a statement.

Either way you slice it, it is a misadministration. You read the vial and doublecheck the order. That obviously didn’t happen.

It is much like the rules of handling a firearm. If you follow those rules you will not have an accidental discharge. Any time you read about an accidental discharge, it is because one of the rules have been broken. There are exceedingly rare cases where it was a equipment failure, but that is generally how it goes.

When someone misadministers a pharmaceutical, it is almost ALWAYS because a step was not carefully observed. It doesn’t mean they are a bad person, they made a mistake.

There is a relatively new thing I really think is a good idea in medicine called “Just Culture” which instead of taking an adversarial approach to finding root causes to issues like this, it is more knowledge and improvement based than punitive.

Not everyone who makes a mistake should be fired. It doesn’t mean that won’t happen if the reason is overt neglect and unprofessionalism, but people shouldn’t lose their career due to a mistake. If the process can be improved and others can learn from it and keep it from being repeated on another patient, there is value in that.

It makes people more willing to talk about issues.

Nobody ever wants mistakes like that to occur, and the person who made the mistake is generally crushed by having made it. I made one early in my career with a radioactive isotope decades ago, and instead of being pilloried and fired because of it, we learned...I most certainly did.

I have always subscribed to that saw about if you want a job done right and perfectly, you get the person who made a mistake on it before and learned from it, because if they are a dedicated professional, they will never make that mistake again.

Administration: Julie Miller (julie.z.miller@wv.gov)

Nursing: Julie Miller (julie.z.miller@wv.gov)

Environmental: Phyllis Lowe (phyllis.l.lowe@wv.gov)

Threat Preparedness: Lisa Holstein (lisa.m.holstein@wv.gov)

BOH Chair: Onia Jane Howell

Health Officer: Philip A. Galapon, MD

http://boonecountyhealthdepartment.org/

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