September 16, 2021
Apology and Explanation regarding an Accidental Injection with a Used Syringe during the COVID-19 Workplace Vaccination Drive
On Monday, September 13, it came to light that during the COVID-19 workplace vaccination drive on Ritsumeikan University’s Osaka Ibaraki Campus (OIC), an incident occurred on Tuesday, August 31 where a nurse accidentally used a used syringe to inject another person.
We express our sincerest apologies to all the individuals who were vaccinated that day and anyone else involved in the vaccination drive for the inconvenience and concern this incident has caused. We will provide guidance and supervision to the institutions subcontracted for the vaccination drive and ensure the thorough management of their operations to make sure this kind of incident never happens again.
1. Course of Events Leading to the Accident
• In the afternoon of Tuesday, August 31 at the OIC vaccination site, a nurse dispatched by the Kansai Association of Health and Welfare, to which Ritsumeikan University has outsourced vaccination services, accidentally injected a person with a syringe that had been used on another person
• Between 15:30 and 17:30, when the nurse in question was on duty, to accommodate those who wished to be vaccinated in the supine position (i.e., laying down in bed), the nurse carried a tray containing about 10 vaccine-filled syringes into to the first aid room where people wishing to be vaccinated in the supine position were waiting.
• The nurse returned the used syringe to the tray holding the unused syringes, and when they returned to the vaccination room, the next person waiting for their vaccination entered, which surprised her and they forgot to discard the used syringe. They randomly took a syringe from the tray, and failing to check it, they used it for the next vaccination. After inserting the needle, the nurse realized that it was a used syringe because it had no fluid inside. Flustered, they did not report the incident at that time. Since the remaining number of vaccines would not match, they discarded one unused vaccine-filled syringe.
• On Monday, September 13, the nurse reported the aforementioned facts to the Kansai Association of Health and Welfare, to which Ritsumeikan University has outsourced vaccination services, and the Association contacted the university on the same day.
• After this incident came to light, we immediately held a hearing with the relevant parties and attempted to identify the person who was injected with used syringe, but we were unable to identify them.
* At Ritsumeikan University, individuals vaccinated in the supine position are vaccinated in the first aid room located next to the regular vaccination booths.
2. Response and Measures to Prevent Recurrence
(1) Our response going forward
On Wednesday, September 15, we reported this incident to Ibaraki City Hall and the Ministry of Education, Culture, Sports, Science and Technology. Ibaraki City Hall then reported this to the Ministry of Health, Labour and Welfare. Since we still have not identified the person vaccinated with the used syringe, we have been contacting everyone (81 people) who received vaccinations at OIC between 15:30 and 17:30 on Tuesday, August 31 when the nurse in question was on duty to apologize and explain the course of events as well as to confirm their health condition and ask them to take a blood test and antibody test for safety’s sake.
(2) Measures to prevent recurrence
• We will review the rules for giving vaccinations in the supine position (i.e., transportation of vaccines and disposal methods) and take thorough measures to ensure that used and unused syringes are not transported together.
• We will re-enforce the awareness of the need to immediately report any mistakes to the person in charge as soon as they occur.
• We will add a log (reception slip) that allows for the prompt identification of relevant individuals when a mistake occurs.
• In addition to once again ensuring strict adherence to the vaccination manual and other guidelines provided by the Ministry of Health, Labor and Welfare, we will share this incident with all staff members and take thorough measures to prevent recurrence.