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Last Friday I took my mother-in-law, Margaret, for her vaccination at a local vaccination centre in Chiswick, London. First let me start with what is being done well. We received a call from our GP practice nurse on Thursday offering Margaret an appointment for the Pfizer vaccine the following day. Margaret is 77 and, because several over-80s had cancelled or declined appointments, GP practices had been contacted to open up the appointments to the clinically vulnerable over 75s. Once defrosted, the Pfizer vaccine has to be used; so to avoid waste, they had proactively sought to get other patients to use up the appointment slots that were free. The GP practice nurse forewarned us about the queues, so my husband and I were able to safety plan to ensure Margaret, who is wheelchair bound and has chronic obstructive pulmonary disease (COPD) and hypertrophic cardiomyopathy, would not be queuing in the cold for an hour. I am sure you have seen the news stories about non-socially distanced, long waits outside vaccination centres in the media this weekend. Patient safety concerns: Social distancing – before.* Once inside the vaccination centre, it is not physically possible to maintain one-metre plus social distancing as the centre is so busy. All staff were wearing masks. Most patients and carers were too, but some patients have exemptions. A positive in our centre is that the windows were all open and the staff were doing their level best to ventilate the room. However, we ended up in a cubicle far away from the windows, close to the door, and so there was a flow of patients, carers and staff who, even with their best efforts, could not maintain social distancing. Social distancing – after. After receiving the vaccination, patients are asked to wait 15 minutes before leaving. This is to ensure they are observed for a period of time in case they have an adverse reaction. It is best practice in vaccination administration and adheres to national and manufacturers' guidelines. However, in following best practice, patients and carers are kept in an environment where social distancing is not viable for a time period which increases the risk of COVID-19 transmission. I am wondering if there needs to be a policy-level conversation about trading off the risk of transmission versus adverse transfusion reaction? Or do we need to reflect on the side effect of the goal to vaccinate the most clinically vulnerable as soon as possible may be introducing congestion risks at vaccination centres? Is there scope to reduce the 15 minute observation period post-vaccination? I know some GP practices and community pharmacies have reduced the observation time frame for flu vaccines. Consent. As the cubicles are back to back, you can hear the conversation with the patient in the next cubicle. Next to Margaret was a lady who at first was not clear why she had been sent for the appointment and who then spent around ten minutes with both a nurse and doctor trying to decide whether she wanted to consent to have the vaccine or not. She did not come across as someone who had lacked capacity, rather just unclear about why she had been sent for and who then (understandably) had to ask the questions she needed answering. My reflection is that the consent conversation needs to start when the appointment is booked or confirmed over the telephone. This happened for Margaret, and it meant that on the day of the appointment staff were able to quickly confirm consent, check if she had had reactions to previous vaccines, taking anticoagulation medication or symptomatic, before administering the vaccine. If a patient is having surgery, good consent practice is to start the consent conversation at the outpatient appointments. Then confirm it on the morning of the procedure. Human Factors and the last task step in a sequence of tasks. It is a well documented source of human error that human beings have a tendency to omit the last task step in a sequence of tasks if the primary goal has been achieved before the last task step occurs. Think photocopying and walking away from the photocopying machine once you had done the photocopying, then realising that you have left the originals on the flatbed. In the context of vaccination centres, the last task step is getting the patient and their carer out of the building after they have been told they can leave. In our case, this meant being directed to a small lift which the over-80s were crowding into. Some had walking sticks, so the stairs are not an option. Some just were not aware of the risk of crowding in a lift with other folk. There was no-one managing the exit process from the building, so there was congestion in the lift area, stairwell and the lift itself. My point is that we need to identify vaccination centres where the environment is suited to the user (i.e. over-75s who may have mobility issues) and where over-crowding at entry and exit points are thought through/planned for. Guidelines and staff deployment/education needs to cover the omission of the last task step problem in the vaccination centre context. Otherwise the exit becomes a transmission hotspot. I am mindful one response to my reflections may be that the risk is not that great because the patients have been vaccinated by the time they leave. However, my understanding is that the vaccine is not effective for a few weeks and it is only patients who are vaccinated. The carers/relatives who accompany them are not eligible to be vaccinated yet, so are very exposed. Many of the relatives/carers I observed were in the 50s or 60s, and they, like me, were accompanying a loved-one who was frail. Regulators and Public Health England might find it useful to use the discussion threads on community websites to capture patient and carer feedback. Charles Vincent, Susan Burnett and I have written on the importance of soft safety intelligence like this in our Health Foundation-funded Measurement and Monitoring of Safety Framework. The discussion forum on Chiswick's website, for example, provides a timely feedback mechanism. Given the social distancing challenges I have mentioned, is anyone measuring how many patients get COVID-19 in the weeks between being vaccinated and the vaccine taking effect? And how many accompanying carers? We need to be measuring potential transmission in vaccination centres in the same way we trace back whether a patient has visited a restaurant, supermarket, had contact with school children etc.. What do you think? The staff at the vaccination centres are another example of our wonderful NHS teams; doing their best in an environment not best suited to the task. Let’s not forget they too may be at risk; so as well as the patient safety issues I have highlighted, we need to get the task and environmental design right to keep NHS staff safe. Going forward, we need to proactively iron out these safety issues. Otherwise, we may find in a few months time that vaccination centres have been a breeding ground for the fourth wave. *For other patient and carers' views click on the Forum tab on www.chiswickw4.com, and the thread started on 6 January referred to as 'the over-80s queuing for the vaccine.'