PUEBLO, Colo. — Rosalee Pike, 82, went to get her coronavirus vaccine, but ended up getting injected with an empty syringe.
Many questions remain unanswered as to how trained medical staff didn't notice the empty syringe before injecting the needle into someone's arm.
Rosalee's granddaughter, Jamie, took her grandmother to get her first round of the COVID-19 vaccine at the public health COVID-19 clinic set up at the Pueblo Mall on Jan. 12.
After Rosalee received the shot, the two pulled into the post COVID vaccination waiting zone.
"We were in the parking lot waiting 15 minutes to see if she had a reaction," Jamie Withnell said. "Then we were notified that there was a problem with her vaccine and that she never received it."
Jamie immediately pulled out her phone and took a second look at a picture she snapped just moments before her grandmother was injected.
"I zoomed in on the syringe and the plunger was all the way down," Jamie said. "There was nothing in it."
If you take a closer look at the syringe, it appears empty.
"If I didn't have that picture, I would have really hesitated to even have her go back in for a second one because I didn't want her to receive two (vaccines)," Jamie said.
News5 Investigates obtained a copy of the Pueblo Health Department incident report.
"Prefilled syringes had been delivered to my work station," the medical staff worker stated. "When I took a syringe and injected the vaccine---the syringe was empty."
Jamie also reviewed a copy of the incident report which she says matches what staff told her at the vaccine site location.
Still, she wants to know how a medical mistake like this happened.
"If they were able to be prefilled, I'm curious to know why there were empty syringes on a work station to be grabbed," Jamie said.
It's one of many questions we have for Randy Evetts, the director of the Pueblo Department of Public Health and Environment.
Since Monday evening, News5 has been asking for an interview with Evetts to discuss this case and protocols for COVID-19 vaccine distributions.
At the time of publication, Evetts has not responded to our request for an interview.
However, News5 Investigates can confirm Evetts is aware of the incident because his signature is on the incident report.
We also shared this finding with the public information officer/spokeswoman for PDPHE on Tuesday.
"I'm concerned because this population is 70 and older," Jamie said. "I hope it's the only case but my worry is that there might be more."
At this point in time, we have no evidence to suggest a widespread problem with vaccine distributions, but we still have questions for Evetts to find out whether proper protocols were followed in handling this case and what precautions may have been implemented since this incident so that another case like this does not happen.
This is a developing story and will be updated as new information becomes available.
Do you have a problem or issue you'd like our News 5 Investigates team to look into? Send an email: News5Investigates@KOAA.com
FAQ's and transparency report:
Q: In an era of claims dealing with "fake" news and sensational headlines, how were you able to fact-check and verify this story prior to air?
A: We first started by asking the patient's family to provide us with a copy of the incident report. Whenever there's a medical-related incident, it's usually documented somewhere for liability reasons and a follow-up review. News 5 then submitted an open records request to the Pueblo Department of Public Health and Environment to obtain a copy of the same incident report. We compared the report line by line to make sure it wasn't altered in any way. As a third layer of verification, we sent a copy of the incident report directly to the PDPHE public information officer so they have access to the same information we have.
Q: How do you know the photographs you were provided were not staged or altered?
A: The photographs provided match exactly what was in the incident report. We actually have multiple pictures in our file. One shows the first injection going into one arm while the other shows a second injection going into the other arm. Although two doses of the vaccine are required, medical staff do not administer both vaccines at the same time. This evidence shows an error was made and later corrected.
Q: You "broke" this story on January 21. Did you give the health department time to respond prior to running your story?
A: Absolutely. Our first inquiry to the Health Department was sent on Monday, January 18. A follow up email was sent on Tuesday the 19th and a third follow-up email on the 19th included a copy of the incident report we obtained as well as an open records request to verify the information we had already been provided.
Q: If Randy Evetts, Pueblo's Public Health Director eventually agrees to an interview, will you update this story?
A: Absolutely. We have many unanswered questions and our offer to sit down and discuss COVID-19 safety protocols regarding vaccine distributions is still an important and relevant topic in our community. If Mr. Evetts agrees to an interview, and updated story will be published accordingly.
After the publication of this article, Sarah Joseph, the spokesperson for Pueblo Public Health sent KOAA News 5 the following statement:
Safety is the utmost concern for Pueblo Deptartment of Public Health and Environment. We confirm that a contract nurse administered an empty syringe to an older Coloradoan, mistakenly thinking it was filled with a vaccine. The syringe was new, and there was no risk of it being used, as used syringes are discarded immediately, per normal safety protocol. The mistake was discovered through PDPHE’s normal safety processes. As soon as the mistake was discovered, we consulted with our top medical officer and determined that the person was safe. The individual then received a vaccination. Although the mistake was isolated to this one case, we have since instituted additional safety measures to ensure this doesn’t happen again- limiting the number of people filling syringes and having fewer additional people in the room. We are reviewing safety protocols with all contracted-nurses again and provide safety briefing each day before the vaccination clinics begin. Pueblo has administered over 3,500 vaccines to individuals ages 70 and older and over 9,743 vaccines to date in the community. Safety is a top priority during the vaccination clinics in Pueblo.
After this statement was issued, Chief Investigative Reporter Eric Ross re-connected with Joseph via telephone and via email to renew our ongoing request to speak with Mr. Evetts about updated safety protocols regarding the distribution of the COVID-19 vaccine in an on-camera interview. Joseph said she would check on Evetts' schedule and get back with us. We'll be sure to update you if our request is granted.