The Shot Heard Round the Room

Fallout from nurse's error with same syringe, many patients

As scores of employees of a New Jersey drug company paraded through a corporate meeting room to take advantage of a free benefit — an annual flu shot — something was amiss.

An alert observer noticed that the nurse who was administering the shots was discarding the needles after each patient, but using the same syringe on several people.

The breach in flu-shot protocol on Sept. 30 sent Otsuka Pharmaceuticals and the New Jersey Department of Health scrambling to alert 67 workers at the Princeton offices that they may have been exposed to infectious diseases. Some employees were unaware of the situation for more than 48 hours.  

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“The New Jersey Department of Health (NJDOH) was contacted immediately once we learned of the breach, and we worked closely with the NJDOH to ensure that the individuals who were vaccinated were properly notified of the low but potential risks,” Otsuka officials said in a statement.

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“Our highest priority at this difficult time is to help these individuals get all of the necessary information and health resources they need.”

An alert employee noticed the nurse was using the same syringe over and over again.

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The affected employees are being screened for HIV and hepatitis. Otsuka directed its employees not to discuss the matter publicly.

“We were upset and alarmed when we learned that a nurse, affiliated with TotalWellness, the company we retained to provide free flu shots for our employees, had breached vaccination protocols during what should have been a routine flu shot clinic,” the company said in its statement.

TotalWellness is an Omaha, Nebraska-based national service provider contracting with companies that include Google, Wells Fargo, and Target on health and wellness programs. The nurse involved is a subcontractor to TotalWellness.

“We take full responsibility for this incident,” Alan Kohil, president and founder of TotalWellness, wrote in an e-mail to LifeZette. “Our sincerest apologies go out to all those affected by this terrible event.”

TotalWellness is working closely with the New Jersey Department of Health to ensure all potential victims are contacted. They also are investigating why proper procedures were not followed. The nurse involved is being investigated by the state Board of Nursing, which will determine any disciplinary action, up to and including a revocation of the individual’s license.

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TotalWellness has implemented new guidelines to ensure vaccination procedures include total awareness for patients.

On Wednesday, Kohil wrote: “As of today, we have implemented new company-wide procedures for prevention purposes:

  • Each participant will receive, at the time of their vaccination, an addendum to the consent form that outlines the vaccination procedure. 

  • Nurses will verbally ‘walk’ every participant through the vaccination process, and the 
participant will be asked to sign the addendum to verify that they witnessed proper vaccination administration procedures.

It is our hope these actions will prevent any future incidents and reinforce our commitment to quality care.”

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