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Second incident discovered at COVID-19 vaccine clinic that injected elderly woman with empty syringe

Documents: Two incidents within 15 minutes of each other
COVID-19 Vaccine
Posted at 3:40 PM, Jan 26, 2021
and last updated 2021-01-27 11:11:18-05

PUEBLO — Earlier this month, News 5 revealed that an 82-year-old woman was injected with an empty syringe at the Pueblo Mall's COVID-19 vaccine distribution clinic.

COVID-19 Vaccine
Public Health Director Randy Evetts

Randy Evett's, Pueblo's top health official called the incident an "isolated case", but now we've reviewed new records showing health officials encountered another problem just a few minutes before this case.

Rosalee Pike
Rosalee Pike

As we reported, Rosalee Pike had to get an injection twice after the first syringe didn't contain the COVID-19 vaccine.

"We were notified that there was a problem with her vaccine and that she never received it," Rosalee's granddaughter, Jamie Withnell said.

After receiving the bad news, Jamie pulled out her phone and took a second look at a picture she took just moments before her grandmother was injected.

According to the photograph---the syringe appears to be empty.

Empty vaccine syringe
Empty vaccine syringe

"I zoomed in on the syringe and the plunger was all the way down---there was nothing in it," Jamie said.

News 5 Investigates obtained a copy of the incident report where a contracted nurse confirmed Jamie's suspicions.

"Prefilled syringes had been delivered to my work station," the medical worker stated on an incident report. "When I took a syringe and injected the vaccine, the syringe was empty."

First incident report
Incident report obtained by News 5

Rosalee was able to go back and get a second injection which contained the vaccine, but the medical mistake left Jamie with a lot of unanswered questions.

"I'm concerned because this population is 70 and older," she said. "I hope it's the only case. My worry is that there might be more."

In a statement, Public Health Director Randy Evetts said the mistake was isolated to this one case.

However, we uncovered it wasn't the only issue that day.

Rosalee was injected with an empty syringe at 10:45 a.m. on January 12, 2021.

Just 15 minutes earlier on the same day and at the same vaccine site, a second incident was reported.

Second incident
Incident report obtained under Colorado Open Records Act (CORA)

This time a nurse injected another patient and during the injection, the tube broke off from the hub of the needle.

The incident report states that the COVID-19 vaccine spilled onto the patient's arm and was cleaned up.

A second injection was ultimately given.

According to data a spokesperson provided to News 5 late last week, more than 3,500 vaccines have been administered to people 70+.

At this point in time, we do not have any additional evidence or documents revealing any other incident at the Pueblo Mall site location.

FAQ's and Transparency report:

Q: What questions has Mr. Randy Evetts failed to address?
A: In a universal media statement issued after our original story aired, the health department said that additional safety measures have been implemented to prevent a case like Rosalee's from happening again. This reportedly includes limited the number of people filling syringes and having fewer additional people in a room. However, Evetts has not responded to repeated requests to talk with us to go over specifics. Some of the questions we still don't have answered include:
(1) Who is in charge of prefilling syringes?
(2) What qualifications do they possess?
(3) Is there any oversight to ensure syringes are filled correctly before being distributed to the vaccine clinic booth?

Q: It's our understanding that there is a safety briefing conducted each day with contracted-nurses before the vaccination clinics begin. What's discussed in those briefings?
A: This is another question we have not been able to ask Evetts. On Thursday, January 21, Chief Investigative Reporter emailed spokesperson Sarah Joseph and spoke with her by phone to re-address our interview request and its importance. Joseph said she would check with Evetts' schedule. At the time this article was published, we have not received any further correspondence from the health department.

Q: How did you obtain incident reports related to this story?
A: In Rosalee's case, the incident report was provided to us by the family. However, in our routine fact-checking process, we submitted an open records request to obtain a copy of the report directly from Pueblo Health for comparison.

Q: How did you verify that a second incident occurred 15 minutes prior to Rosalee's case?
A: Rosalee's granddaughter feared there may have been other incidents out there that we did not know about. News 5 submitted an open records request using the Colorado Open Records Act (CORA) to obtain copies of any and all incident reports filed from the Pueblo Mall vaccine location.

Q: Are the incident reports obtained by KOAA 5 public record?
A: Yes. Before they were released, confidential information such as a patient's date of birth and phone number were redacted beforehand to comply with records laws and confidentiality.

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