Error at the vaccination center, physiological in place of Pfizer for six people – Chronicle

Error at the vaccination center, physiological in place of Pfizer for six people – Chronicle
Error at the vaccination center, physiological in place of Pfizer for six people – Chronicle

Pistoia, 11 June 2021 – Physiological solution instead of vaccine: it happened this afternoon at the San Biagio vaccination center in Pistoia . Six people who thought they had received the vaccine Pfizer instead they received only physiological and therefore are not vaccinated. There are no health risks, of course, but the mistake requires identifying the subjects who think they have received the vaccine: there are six people.

How did it happen

The vaccination team realized that they had used one less vial than would have been necessary to vaccinate the people registered in the box up to that moment, carrying out a periodic congruence check between the doses administered and the drugs taken from the refrigerator.

The people vaccinated in the afternoon shift up to the time when the event was detected are 36, 30 of which have been correctly vaccinated. The health care worker mistakenly diluted with saline one of the ampoules already used, devoid of active ingredient. The dilution operation was carried out in compliance with the rules of sterility. The six people to whom the saline solution was administered are not at risk, nor have they suffered any harm from the administration.

The research of the six subjects

It will be the responsibility of the USL Company to contact all 36 users on Saturday 12 June to notify them of the fact that, during the vaccination session, some people have received physiological solution and not vaccine. Even though the six users who received physiological solution are identifiable following the reconstruction of the events conducted so far, the Company, after 28 days, will propose blood sampling to check the antibody titers for Covid to all 36 users. The result of the survey will make it possible to identify the 6 unvaccinated people, who will be offered a new vaccination cycle.

The USL Company will activate its own Clinical Risk team to perform audits on the dynamics of the session and to analyze any weak points regarding the implementation of the vaccination procedure.

I am deeply sorry about what happened “– declares the general manager, Paolo Morello Marchese. “I would like to point out that none of the users risk damage to their health following the administration of physiological solution. Once the necessary laboratory investigations have been carried out, the USL will promptly undertake to carry out a new vaccination cycle for the six citizens ”.


In Tuscany it is the third mistake that occurs during the vaccination campaign, although less serious than the other two when two women were given excess doses of the vaccine. The first case was a Pulp, when a young woman was given four doses of the vaccine, the second case a few days later a Livorno, always with four doses given to a woman by mistake.

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