An independent report into the under-dosing of over 1,200 patients with seasonal flu vaccine by some pharmacists has found that the primary cause was incorrect training on measuring the dose for administration.
It says that 203 of 1,462 pharmacists trained were using the wrong dosing instructions and as a result 1,231 patients were incorrectly vaccinated.
The report says it is of concern that the vaccination service was under way for six weeks before the error was detected and the error was not reported and recorded in any national system.
It also says that as of late April this year, 47% of patients had been revaccinated, significantly less than the 80% self-reported by pharmacists via the training body.
The review group says it is not in a position to establish the actual number revaccinated following the mistake.
For the 2011/2012 influenza season, pharmacists were allowed for the first time to participate in the campaign.
The report supports moves to maximise seasonal influenza vaccination uptake, including increased participation by pharmacists, but it says that in future, the recognised training body must have access to internal and external expertise in the subject.
In November 2011, a superintendent pharmacist noticed a difference between the instructions on measuring the dose of vaccine in a video by the training company, Hibernian Healthcare, and the instructions set out in the product documentation.
The report of the Risk Review Group has been published by the regulator, the Pharmaceutical Society of Ireland, on its website.
