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More than 200 people are being contacted to repeat their COVID-19 vaccinations because some who attended an immunization clinic in the Niagara region were injected with a saline solution instead of the shot. Niagara Region Public Health said Tuesday that six people were injected with the harmless saline substance on June 16 at a clinic in Port Colborne, Ont.

An end-of-day audit found six administered doses had not been accounted for and an additional vial of a saline diluent had been used. The diluent is meant to be mixed with the Pfizer-BioNTech vaccine concentrate and while not harmful, it doesn’t protect against COVID-19.

Dr. Mustafa Hirji, the region’s top doctor, said the health unit wasn’t able to identify the six people who didn’t receive the vaccine.

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“Unfortunately, with the size of the clinic going on and the nature of the provincial documentation tool for vaccination, there’s no current tracking of individual doses of vaccine,” Dr. Hirji said.

However, he said public health was able to narrow down a timeframe when the doses would have been administered, identifying 205 people out of the 1,148 who received shots that day.

Those individuals were being contacted to book a repeat vaccination after an appropriate dosing interval. The majority will be getting a third COVID-19 vaccine dose, which the health unit said is safe but doesn’t provide additional benefits.

The health unit said a review was conducted to investigate the error that occured, and new dose tracking and training protocols have been introduced to avoid similar situations.

Dr. Hirji said the changes include involving more staff members in double-checking others’ work, more detailed documentation in clinics and a plan to track each dose from the freezer to the patient who received it.

“The goal here is, of course, that there won’t be another time, by having these double checks to make sure we stop the error before it happens,” Dr. Hirji said. “If unfortunately there is another error we would be able to narrow it down much closer to just six people.”

Dr. Hirji said he doesn’t believe similar situations could have happened at other Niagara Region clinics based on the checks and balances that helped identify the problem by the end of 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 York Region, advised the public of a similar error in April, saying it contacted the six people who were injected with saline by mistake instead of a COVID-19 vaccine.

“Our internal quality assurance processes allowed us to identify this issue in a timely manner and contact the impacted individuals to disclose the issue, offer support and have them tested for antibodies to identify those who needed to be re-injected with vaccine,” Mackenzie Health said in a statement at the time.

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