Iowa fires 2 prison nurses who gave coronavirus vaccine overdoses to 77 inmates

[cigaretteman]

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The Iowa Department of Corrections has fired two nurses who gave large overdoses of coronavirus vaccine to dozens of inmates at the Fort Madison prison in April, an agency official said Monday.

Department spokesman Cord Overton said in an email to the Des Moines Register that the nurses had been terminated. Overton did not identify them, or cite a legal reason for keeping their names private.

The incident happened April 20 at the maximum security prison for men. Authorities said at the time that 77 inmates were given up to six times the proper dose for the Pfizer version of the coronavirus vaccine. The department has never explained how the overdoses happened.

Overton said in April that the inmates suffered normal side effects of the vaccine, such as fatigue and body aches, and none of the inmates suffered side effects that required hospitalization.



"The inmates that received doses in excess of what is recommended have been monitored, and all are in good health based on our medical staff’s assessments," Overton wrote in an email to the Register Monday. "Facility medical services continue to be available to them if their health status should change."

Overton told the Register earlier in June that results of the investigation into what happened would be confidential.

The overdoses reportedly happened after the prison switched from using the Moderna brand of vaccine to the Pfizer brand. Independent experts told the Register that the Moderna vaccine comes pre-mixed, but the Pfizer vaccine is shipped as a concentrate and is supposed to be substantially diluted with saline solution before being administered.

After the Register reported on the overdoses, the state employees' union said poor training was to blame. Representatives of the union, the American Federation of State, County and Municipal Employees, said the nurses were only given 90 minutes notice of the switch to the Pfizer vaccine.

The Department of Corrections denied the union's allegation, saying that the nurses were given proper instructions, and that they were assigned to work in pairs "in order to prevent this exact type of event from occurring."

The department reported in April that the two unidentified nurses had been placed on administrative leave. Overton's confirmation Monday of their termination came in response to a Des Moines Register inquiry into the status of the case. He said any results of the investigation into the incident would be confidential, although he didn't cite a reason why.

Iowa fires 2 prison nurses who gave coronavirus vaccine overdoses to 77 inmates

The overdoses happened after prison nurses switched to the Pfizer vaccine, which supposed to be substantially diluted before being administered.

www.press-citizen.com

 

[Old_wrestling_fan]

??? Admittedly, there is much about this scenario that I don't understand, but...are you telling me that a major vaccine manufacturer distributes a vaccine in concentrate form where later someone has to mix it right before administering?

If so, I can't get my head around that approach. Why would any vaccine be left to "field" mixing? This introduces variables and potential lack of quality control...something I don't get at all. Is this common?

 

[anon_ddojbbh8q7xrt]

It says the nurses had 90 min notice of the switch. Ok. But they’re freaking nurses. Certainly they have heard of the Pfizer vaccine prior to that 90mins. And you’d think as health care workers theyve heard hey the Pfizer version is different than Moderna.
Also why are the processes different between Moderna and Pfizer? Shouldnt the CDC require standardized dissemination practices. The federal government is paying a shitload of money. Is it too much to ask these 2 companies to be on the same page. Im assuming this is just another case of pharma cutting corners to save money at the expense of peoples lives

 

[lucas80]

??? Admittedly, there is much about this scenario that I don't understand, but...are you telling me that a major vaccine manufacturer distributes a vaccine in concentrate form where later someone has to mix it right before administering?

If so, I can't get my head around that approach. Why would any vaccine be left to "field" mixing? This introduces variables and potential lack of quality control...something I don't get at all. Is this common?

I don't know if this is common, but this was not something new. Your local pharmacist isn't always pulling a 100 precent pre-made medicine for you if it is in liquid form.

 

[Old_wrestling_fan]

I don't know if this is common, but this was not something new. Your local pharmacist isn't always pulling a 100 precent pre-made medicine for you if it is in liquid form.

As I said, there is much I do not know about vaccine distribution, but I would have never guessed that it would a thing where a nurse, etc, would be determining the final dosage strength via dilution or reconstitution, etc.

Could this practice, assuming that it is common, explain some of the reported problems with vaccines? That is, someone screwed up and delivered 10x the drug??

I am quite surprised to learn that the final dosage strength is left to someone doing "math", etc, for really any vaccine. Is this something that a pharmacist should have done, not a nurse, etc?

 

[onlyTheObvious]

Did the pull their “hero lives here” signs from their yards?

 

[UKGrad93]

An RN should be capable of diluting a drug. Diluting and reconstituting are not considered compounding (which would require a pharmacist). RNs are routinely responsible for setting up IV pumps to deliver drugs at a certain rate and have to do calculations for that. Even as a lowly EMT, my skill set included learning to set a drip rate for a drug.

I also think that other factors could have been in play here: the short notice of the switch, not enough time to properly prepare, over-worked due to covid, motor memory kicking in, etc... I'd have to know more about their work histories to know if this is a one off thing or a pattern of poor attention to detail.

 

[Old_wrestling_fan]

An RN should be capable of diluting a drug. Diluting and reconstituting are not considered compounding (which would require a pharmacist). RNs are routinely responsible for setting up IV pumps to deliver drugs at a certain rate and have to do calculations for that. Even as a lowly EMT, my skill set included learning to set a drip rate for a drug.

I also think that other factors could have been in play here: the short notice of the switch, not enough time to properly prepare, over-worked due to covid, motor memory kicking in, etc... I'd have to know more about their work histories to know if this is a one off thing or a pattern of poor attention to detail.

FWIW, now you have me thinking...I am not a big consumer of medical care, so my personal experiences are limited in this area, but about 15 years ago I was very foolish and the net result was a serious infection on my hand that required IV antibiotics for ?? 4 days ?? I think.

I had to stay overnight in the hospital on night one and then was released and came back once a day as an outpatient for the next IV dosage. On one of those visits, the RN totally screwed it up and my outcome was that I got NO antibiotics, only the solution that was the other half of the treatment. So...after having to sit there for an hour or so before this was discovered, I had to have the whole thing restarted and stay for another hour. Harrumph!

Point being...humans make mistakes, even well trained ones. I am still surprised to learn that things would be left up to human interaction in the mixing of a vaccine.

 

[stout1]

T&Ps for IMCC losing his job...

 

[GOHOX69]

Most vaccines come either lyophilized (freeze dried) or in concentrated liquid form. The local pharmacists then compound them by diluting them etc. It's very very common and long established. Someone screwed up.

 

[Gimmered]

FWIW, now you have me thinking...I am not a big consumer of medical care, so my personal experiences are limited in this area, but about 15 years ago I was very foolish and the net result was a serious infection on my hand that required IV antibiotics for ?? 4 days ?? I think.

I had to stay overnight in the hospital on night one and then was released and came back once a day as an outpatient for the next IV dosage. On one of those visits, the RN totally screwed it up and my outcome was that I got NO antibiotics, only the solution that was the other half of the treatment. So...after having to sit there for an hour or so before this was discovered, I had to have the whole thing restarted and stay for another hour. Harrumph!

Point being...humans make mistakes, even well trained ones. I am still surprised to learn that things would be left up to human interaction in the mixing of a vaccine.

I had an infection in one of my artificial knees. Cleaned it out and had to do 6 weeks of IV antibiotics. They put in a picc line and taught my wife how to give me daily antibiotics at home. I was on my best behavior for the duration.

 

[UKGrad93]

FWIW, now you have me thinking...I am not a big consumer of medical care, so my personal experiences are limited in this area, but about 15 years ago I was very foolish and the net result was a serious infection on my hand that required IV antibiotics for ?? 4 days ?? I think.

I had to stay overnight in the hospital on night one and then was released and came back once a day as an outpatient for the next IV dosage. On one of those visits, the RN totally screwed it up and my outcome was that I got NO antibiotics, only the solution that was the other half of the treatment. So...after having to sit there for an hour or so before this was discovered, I had to have the whole thing restarted and stay for another hour. Harrumph!

Point being...humans make mistakes, even well trained ones. I am still surprised to learn that things would be left up to human interaction in the mixing of a vaccine.

Glad you survived.

When I think about the logistics involved in shipping these vaccines, it makes sense to ship them concentrated. Less volume to have to keep cold, less weight on the delivery truck. Have them diluted on site with common supplies.

I believe it is common to do investigations for medication errors. Sometimes it is just human error, but sometimes there is something in a procedure or workflow that needs to change. I know of a case where a (very experienced) nuclear medicine tech needed to administer a PET tracer to a patient. Walked in and asked the patient are you Jane Doe and is your birthday Dec. 23. The patient responded yes. The tech gave the radioactive drug and started chatting with the patient. Eventually found out that she had administered to the wrong patient. The patient had already received her rad tracer drug and was waiting to be imaged. The tech should have asked the patient to state her name and birthdate.