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Contractor unplugs freezer and there goes 1,900 doses of Covid-19 vaccine at the Jamaica Plain VA hospital

WBZ reports.

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A spokesperson said the freezer was in a secure location and had an alarm system installed. An investigation is underway to determine why the monitoring and alarm system did not work.

Someone's work email spam folder is chock-full of high temperature alerts. Yikes.

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we have a similar alerts system where I work. One week, we just stopped getting alerts...couldn't figure out what was going on, until finally we asked our accountant. He'd cancelled the recurring payment because it "didn't seem necessary".

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the accountant was deemed "not necessary"?

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WTF would you unplug a running freeze at a hospital ? I wouldn’t even unplug a running freezer in a restaurant kitchen

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One possibility is that the freezer is on wheels and in order to clean throughly, the worker moves the freezer and it unknowingly becomes unplugged. Or if your sweeping or moping behind the freezer unit and the broom/mop pulls the cord and the worker doesn’t notice that the freezer becomes unplugged.

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[spoiler]there is an episode where the cleaning person unplugs the life support in order to vacuum the floor.[/spoiler]

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A cleaning contractor?

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just how many jobs get contracted out through staffing agencies these days. And I'm not just talking short-term fill-in roles or anything, but straight up full-time, working for the actual company everywhere but on paper roles.

In a lot of cases it comes down to benefits. The company gets the benefit of having someone do the exact same job as an "internal" employee or whatever you want to call it, without having to pay out any benefits (vacation, sick time, profit sharing, raises, bonuses, etc.) themselves, and they get to avoid unions where applicable. They just pay the person's hourly rate and a placement fee to the staffing agency, and any benefits are the problem of the staffing agency i.e. the legal on-paper employer. And, you guessed it, they usually only offer benefits that are absolutely required by law...essentially sick days and insurance plans with high premiums and low coverage, even by American insurance standards. No paid holidays, no vacation, no bonuses, etc.

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Janitorial staff at the VA are full time employees, not contractors.

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"'Replenishment doses are in process and we do not foresee disruption of our vaccination effort,' the spokesperson said."

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No one is blaming bad man orange yet, incredible. Yet Biden is preparing patriot act 2.0 to silence any dissent. First they came for my neighbor etcetera etcetera etcetera. When will the “woke” wake up?

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Joe Biden is coming for me, and will make me sit in the comfy chair! Nobody expects the Spanish Inquisition!

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Holding those that were involved in an attempted insurrection accountable is a far cry from "silencing dissent."

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you are mercilessly mocking the kind of right-wing dope who falls for those inane trigger words (in which case, nicely-done bit of parody), or you actually *are* the kind of right-wing dope who falls for those inane trigger words.

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Actual right-wing dope.

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It's amazing how quickly the wingnuts have started yelling about imaginary Biden atrocities. I was hoping they'd go off into a corner and sulk for a while after their fascist champion's epic failure. But nooo ...

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talking about: the insidious China-colluding mastermind, or the senile old guy who can't string two sentences together?

It hasn't dawned on these humps that the reason Trump managed to lose the popular vote twice and pull off the historic feat of losing the Presidency, the House and the Senate all in one term, is that he's in essence an incompetent business leader and a horrible fucking human being.

Had he done the single most important job of his Presidency (handling the pandemic) with the barest level of competence and empathy, he'd have easily won re-election, *epically* owning the libs. Instead, he fucked everybody: his party, his allies, his partners, and most brutally of all, his mouth-breathing worshipers. Oh, yeah, and half a million dead Americans.

Trumpie cognitive dissonance is a hilarious, scratch that, tragic spectacle.

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Remind me again which rightie fantasy Joe Biden we're talking about: the insidious China-colluding mastermind, or the senile old guy who can't string two sentences together?

I guess you missed it. Mandatory same-sex marriages began at 7 am yesterday morning.

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It hasn't dawned on these humps that the reason Trump managed to lose the popular vote twice and pull off the historic feat of losing the Presidency, the House and the Senate all in one term, is that he's in essence an incompetent business leader and a horrible fucking human being.

I mean, literally, if he had just said "Follow the CDC guidelines on Covid", he would have been credited with "leadership" and he would have coasted to a victory.

But either out of a desire to appear to be the smartest guy in the room, or out of concern that his tourism-dependent businesses would suffer revenue losses, he decided to fuck it all up, and now 400,000 Americans are dead.

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Off topic and irrelevant.

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I'm too old for this crap. There are plenty of other sites in the sea for you to cackle on, so I've disabled your account.

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I've disabled your account.

Not all heroes wear capes.

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that the proprietor of this site is depriving the rest of us of the pleasures of derision.

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De-platforming is a helluva drug. It should be used early and often.

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Thanks, Adam.

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MAH FURST AMENJEMINT RITES!!!!!!!!!!

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I thanked Obama after reading this.

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More likely scenario it was never turned on. They just don't want to admit that already given doses are duds.

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Huh?

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I hope there weren’t any Klondike bars in the same freezer that got ruined!

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Given we're in a pandemic, this sounds like criminal negligence.

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Yikes.

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I've seen people causally unplug anything when they an outlet for recharging.

It's also possible the fridge outlet uses a higher amp socket which is the same used for whatever cleaning device he was using. They might regularly use that outlet for their machine so they didn't think too hard about unplugging the fridge so they could connect their floor buffer as normal.

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Pharmaceutical products are kept in secure locations, so only authorized personnel, including cleaning contractors should have access to them.

I've never worked directly with products on *that* end of the pharmaceutical world, but I do maintain critical laboratory equipment. I once had to meet up with a cleaning crew every other Thursday morning for 2 months and watch them clean the floor in 2 rooms with sensitive equipment, before they could be authorized to perform biweekly floor cleanings without an escort. This was done to ensure they knew what could be touched, and what could not be. When they do deep cleanings of the floor once or twice a year, one of my superiors actually stays with them for the full overnight to supervise them, since they have to move equipment around that normally would not be touched.

This is an operational failure at the hands of whoever is managing the pharmacy at the VA. Better safeguards should have been in place to prevent this.

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There was the time a contractor unplugged all the power to the T by mistake.

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L O L

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As the late great Bobby Devlin used to say, prior planning prevents piss poor performance. Bobby was a member and percussion instructor for the US Army Band at West Point, and the Boston Crusaders.

The real issue here is the decision to store critical material in a plug in freezer, rather than a hard-wired freezer with a back-up generator. The poor minimum wage cleaner should not be the scapegoat, nor should the contractor.

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Also possible it was done on purpose to hide the fact that many vaccines were missing (given out to friends, or sold). Nobody is going to count how many vials are in the trash.

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That's the second crack-brained QAnon-esque conspiracy theory from you. It's time for you to put up or shut up.

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Those vaccines were brought to the hospital by national guard units and hustled into pharmacy. Inventory control at the VA is very good, because they deal with so many pain and addiction patients. The fact this is a contractor is not surprising, however, because contractors are how the government gets out of paying actual living wages to competent people, so anyone being brought in on a contract is getting pennies to do a slapdash job and doesn't GAF about anything except their assigned tasks.

It was probably somebody working on mechanicals or IT, and unplugged it to move it to get into a wall. At a guess.

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Oh, yes, they are counted. There's a reason every vial is serialized, and it's not to keep Big Barcode in business.

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It was done by the Joker who's using it as the basis for his new batch of Joker Venom.

If we're just going to make up stories, let's at least have some fun with them!

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I am not assuming this is sabotage, but I can't help but worry.

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I'm referring to "Notfromthisplanet"'s wacky idea that these life-saving vaccines are being stolen and sold and then the rest destroyed to cover the evidence. It's basically a plot out of a Batman movie, just missing the wacky costumes and special effects.

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mAyBe It WaS bIg FoOt

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the FDA would disagree with you, and the requirement of "chain of custody" in this field. Please don't be one of those conspiracy theorists.

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Sadly, I immediately thought of the pharmacist in WI.

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How about a simple cable marker on the plug end that says, "Do Not Unplug w/o Facility Approval"

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I work for a company that designs labs and commissions them, among other things. The freezers that the vaccine are stored in are specialty freezers, not something you pick up at Home Depot, to keep the temperature within tight tolerances. The have on board controls that monitor the temperature that generates an alarm signal as well as local audible alarms and display - the alarm signal is connected to the building controls system that monitor and control the lab mechanical systems (air handlers, VAV boxes, hoods, etc) to alert building operators of the situation, since the freezers are located in secure unmonitored rooms (likely security cameras but no one there to hear the audibles typically). Other alarms are generated if the refrigerator is unplugged or at least should be but mistakes happen. Unplugging should result in a loss of comm alarm, meaning it stopped talking to us. If the alarm isn't set up properly or the power to the controls is unplugged at the same time or is the same source (happens), the controls system doesn't get an alarm. When you consider that each vial contains 30 doses, we're talking just over 60 vials - this wouldn't fill one freezer. So a single freezer was unplugged and before it was caught, the temperature of the vials was too high to trust the efficacy of the vaccine. It's not a conspiracy, just a mistake - see comment above by the lab tech. You need proper training to work in those rooms but you have less control when contractors are used - someone who didn't know better cleaned the room. That's it.

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I watched Congressman Lynch's explanation of what occurred (via the linked article). He claims the contractors pulled out the freezers during the clean-up process, which caused the plug to separate from the receptacle.

Assuming it's a traditional upright biomedical freezer, most of these built-in cords extend at least 5 feet from the unit when attached. That would be a significant pull-away. On some units, when such a freezer is left in the "on" position and becomes unplugged, a high-pitched repetitive warning "beep" is activated, which is built into the unit itself to alert that power is not reaching the unit. Was that ignored? Also, some of the larger units have a 220V plug, which is not easy to pull away from the outlet without some force. (pictured below)
IMAGE(https://www.doityourself.com/forum/attachments/electrical-ac-dc/65048d1460558493-commercial-toaster-120v-but-has-220v-cord-plug-20-amp-plug.jpg)

On some of the lower-end models, a more traditional plug may be utilized, with a shorter cord built into the unit. And there may not be a built-in alarm provided by default. But you can get a manufacturer's add-on alarm.

Either way, there should be an active temperature monitoring system in play here, which should have high & low limits set to activate an alarm signal upon reaching excursions from these limits. Were these not programmed? Was the monitoring system not operating?

Finally, due to these samples being for injection purposes, I wouldn't risk keeping a unit in a room that just experienced a 6" water pipe burst. I would roll this unit into an alternate, appropriately powered area that isn't housing such additional moisture, and either 1) look for another unit with a comparable temperature & surface area to transfer the vaccines into, utilizing multiple personnel, or 2) look for an available 220V receptacle and document temporary freezer operation in an alternate area.

This just screams of a largely avoidable situation that was dealt with very poorly. (Source...a Laboratory Operations Manager, in the field for 17 years.)

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Looks like the power cord was removable from the power supply rather than hardwired, and it was that end that came loose.

https://twitter.com/seracongi/status/1352715864559284224

As for all of the other layers of failure, they remain unanswered.

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there should be an active temperature monitoring system

Our company has some expensive freezers holding expensive reagents. They have alarms which beep when the temperature rises above a set limit. The alarms run on the power coming from the plug. I guess you have to pay more for an alarm which comes with its own power source.

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The alarms run on the power coming from the plug. I guess you have to pay more for an alarm which comes with its own power source.

That setup self-illustrates the problem with that scenario...an alarm running off the same power source is no good, if the source itself potentially fails.

We use wireless transmitters which utilize replaceable lithium-ion batteries. The transmitters have a wired probe connected & fed into the freezer unit, and beam the temperature to a wifi repeater, which is hooked into a dedicated server running the software. If a freezer's power source fails, the transmitter has independent battery power which continues to monitor the increasing temperature excursion, and sends an email/calls a phone with the alarm status.

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And with an external monitor, even if the sensor cannot send the temperature signal, for any reason, it can recognize that the sensor is offline and go into alarm. We better not find out that something went into alarm and no one responded.

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Any alarm that mentions "wireless signal lost" is an action item to address in the moment...not when it's too late. Nice to see your input!

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There are things left if obscure freezers and under refrigeration for years in places that are not frequented. Joe has that 17 year experiment in the freezer up on the unoccupied 8th floor. Years later someone needs to move that freezer that's labeled do not unplug. Then...

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Unfortunate that they lost doses but it exposed a weakness in the storage system. Now they're looking at all the VA Hospital setups so it won't happen again so in the long run, it's a good thing. Now that there's an administration interested in having a working infrastructure for the vaccine distribution and working on ordering more, the vaccinations will ramp up all over and more than just frontline workers will be getting them.

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Congressman Lynch reports that it was a contractor brought in to make repairs after the pipe burst.

https://www.facebook.com/repstephenlynch/posts/3544956135573299

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I feel bad for our Veterans who rely on the VA hospitals for their medical care. These should be world class hospitals. They are not even close to being world class. What a disservice to our Veterans.

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