Kaiser Permanente has notified 3,900 patients vaccinated at their Walnut Creek Medical Center last fall that they may have received less than a full dose of the Pfizer shot.
Kaiser is sending messages this month, offering those who have received the light shots agreements on a “repeat” dose if they want one. However, the HMO said that after consulting with experts and reviewing guidelines from the U.S. Centers for Disease Control and Prevention, the dosing error should not significantly reduce immunity.
“The health and safety of our members and patients is our highest priority,” Kaiser Permanente said in a statement. “As a trusted healthcare provider, we are committed to informing patients about circumstances that may affect them, even if any potential impact is not considered significant, as in this case.”
Patients who received the Moderna or Johnson and Johnson vaccines were not affected.
This is not the first time Bay Area patients have received incorrect doses of COVID-19 vaccines. In November, a pediatric clinic at Sutter Health in Antioch provided 14 children ages 5-11 times the correct dose of Pfizer’s pediatric version of the COVID-19 vaccine.
March last year, KTVU reported that 4,300 people were administered one-third less than the recommended dose while receiving a shot at the Oakland Coliseum Mass Vaccination Clinic. In that case, government officials told the television station that no one was offered additional doses because the dosing error was not considered significant.
Problems have also arisen nationally. Last fall, 112 children at a pharmacy in Virginia received one-tenth of the formulation of the vaccine intended for adults, and 98 children in Maryland received over-diluted doses at a school clinic.
In the latest incident involving Kaiser, the health organization said patients who should have received a 0.30 milliliter dose of the Pfizer vaccine for teens and adults instead received 0.26 to 0.29 milliliter doses between October 25 and 10. December 2021.
“When we became aware of this issue, we immediately consulted with experts in infectious diseases and vaccine science and reviewed guidelines from the Centers for Disease Control,” Kaiser said. “All experts agreed that the difference between the recommended dose and the dose a person may have received was not significant and was unlikely to reduce their protection against COVID-19.”
According to the CDC, vaccine administrators are required to notify patients of any dose errors, report them to the Agency’s Vaccine Adverse Event Reporting System even if they did not cause any problems, and consult with government agencies on how to record the incorrect dose.
That The CDC says that when given a lower dose than allowed for adults, such as when the patient withdraws, the syringe leaks or the equipment fails, the dose should be repeated immediately.
Kaiser said it “took immediate steps to confirm that the problem was isolated and immediately retrained staff and validated their understanding of the correct procedure.”
“We are constantly monitoring so this does not happen again,” Kaiser said. “We sincerely apologize for any concern or inconvenience this may cause to the patients we contact.”
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