September 6, 2019

CIPRIANO C. FERNANDEZ, MDFPSGS,FPCS

OIC-Chief of Hospital
Lingayen District Hospital
Lingayen, Pangasinan

Re: Incident Report and Findings on Bivalent Oral Polio Vaccine (BOPV) and Tetanus
Diptheria Vaccine stored at the NDP-DOH cold storage freezer.

Dear Sir:

This is to inform you that, sometime in the morning of September 6, 2018, while the
undersigned reported back for work from a three (3) day field work (Sept. 3,4 and 5),
was undertaking an inventory of the 343 vials of Bivalent Oral Polio Vaccine (BOPV)
bearing Lot No. 1808P113 (Exp. Date Sept. 2020 and 244 vials of Tetanus Diptheria
Vaccine bearing Lot No. 221502416A (Exp. Date October 2019), stored at the Nurse
Deployment Program (NDP) office of the Department of Health, stationed in the public
health services building of the Lingayen District Hospital, I noticed that the cold storage
freezer/fridge owned by the NDP-DOH was not normally functioning and the normal
freezing point dropped, though the electric plug of the freezer was in placed on the
electric socket source.

Immediate report and investigation upon discovery on the same day was conducted by
the undersigned together with my co-employees in the public health to the concerned
maintenance personnel of the hospital and requested the GSO electrician/s for
assistance. The electrician/s inspected the power source, test for the presence of
electric voltage through their electric device and found out that there was absence of
electric supply from the electric source. Further inspection from the main source (circuit
breaker) was conducted, upon inquiry, it was known and considered that, the circuit
breaker while in the power on mode (power source line supply outlet where the storage
freezer is attached) had normally reached the automatic trip-off due to unavoidable
factors, such as, sudden power failure, fluctuating power supply, ordinary wear and tear
of circuit breaker/s, overloading of electric voltage, or malfunctioning storage freezer.

Regretfully, the vaccines under my watch were damaged, in view of the above-stated
causes which is beyond the undersigned’s control. Due diligence was observed in the
proper handling and storage of the vaccines in the storage freezer, since it was
transported to the hospital facility. Neglect of duty cannot be attributed to the causes
enumerated above.

For your information and perusal.

Respectfully submitted,

CYNTHIA R. SENENSE, RN
District EPI Coordinator

Attested by: Noted by:

ROWENA P. PARAGAS, RN DR. CIPRIANO C. FERNANDEZ

District Nurse Supervisor OIC-Chief of Hospital