A U.S. Centers for Disease Control and Prevention report found Mary Roback, the nurse who used two syringes for 67 flu vaccine shots, committed other blunders. The health agency said these errors are innate in many non-clinical settings where vaccine shots are administered.
Roback was dealt with a temporary license suspension. The investigation showed she did use a fresh needle for each of the 67 flu vaccine shots, but used only two syringes.
However, the CDC's report found both Roback and TotalWellness committed mistakes. TotalWellness is a health and wellness company based in Nebraska that hired the contractor nurse to administer the flu vaccines to Otsuka Pharmaceutical employees.
• The Otsuka Pharmaceutical employees were set to receive the flu vaccine shots from individual pre-filled syringes. However, Roback came with only two large vials of the flu vaccine.
• The two large vials were enough for only 20 people, but Roback completed all 67 shots, resulting in inadequate doses.
• TotalWellness delivered the vaccines to Roback's house where the drugs were stored in a personal refrigerator. Vaccines require a specialized, high-performance refrigerator with exact temperature control. Personal refrigerators lack such ability.
• The vaccines were transported from Roback's house to the Otsuka Pharmaceutical office in a Styrofoam cooler with cold packs. The CDC stressed this is not ideal for vaccine transport and handling.
• Roback used only two syringes for all 67 flu vaccine shots. Roback said she found these two syringes "among her supplies." The syringes were wiped with alcohol between each shot.
• The shots given to the employees were insufficient. The leftover vaccine from the vials were shipped back to TotalWellness. Once again, Roback used a container filled with cold packs.
All the errors point to the necessity of training and management. The CDC also stressed the heavy importance of proper vaccine transport, storage and handling, particularly the need to keep vaccines at a certain temperature to maintain their efficacy.
The employees at Otsuka Pharmaceuticals had to receive new flu vaccines. Due to the errors, the employees also needed vaccines for Hepatitis B and C and HIV. They may also require close monitoring for any implications resulting from the error.
To date, New Jersey Department of Health spokeswoman Donna Leusner reported none of the Otsuka Pharmaceuticals employees had contacted any health implications due to the error. The health department continues to monitor the case with plans for final vaccination and testing set in February 2016.
Photo: Nathan Forget | Flickr
