What was initially thought to be a major human error of someone damaging 57 vials of the coronavirus vaccine at the Aurora Medical Center Grafton has since grown into a federal investigation.
A pharmacist at the facility intentionally removed 57 vials of the Moderna coronavirus vaccine from the refrigerator and left them out overnight knowing the vaccines would be “useless” to those who received them. On Dec. 26, Aurora gave 57 people the vaccine from the tampered vials. After further review the vials were discarded and an investigation into how the vials were left out began.
On Wednesday, Aurora notified Grafton police and it became public that the vials were left out intentionally and on Thursday the pharmacist was arrested. The FBI and the U.S. Food and Drug Administration were also investigating, police said.
More details about incident were revealed Thursday by Jeff Bahr, president of Aurora Health Care Medical Group — part of Advocate Aurora Health who called the pharmacist a “bad actor” during a virtual press conference.
There are major questions as to the motive to sabotage the vials of vaccine, the security protocols in place and the legal action moving forward.
Did the health care worker intend to ruin the vaccine doses?
Yes, according to Grafton police the now-former pharmacist intentionally took the vials out of the refrigerator and left them out overnight knowing it would render the vaccines “useless” and make people who received them believe they were vaccinated when they were not.
What was his motivation for destroying the vaccines?
Aurora says the motive is unknown and law enforcement has not answered that question.
What is the health care worker’s name?
Police and Aurora have not released a name but jail records show Steven Brandenburg, 46, of Grafton, was booked Thursday on similar preliminary charges — criminal damage to property and second-degree recklessly endangering safety, both felonies.
According to the jail, he was brought to the jail by Grafton police.
He has not been formally charged.
A search of state records showed Brandenburg is a licensed pharmacist.
How long was the pharmacist employed at Aurora?
It’s unclear how long Brandenburg was employed with Aurora but he has had a license to be a pharmacist since 1997.
How and where were the vials discovered outside the refrigerator?
According to Aurora, on the morning of Dec. 26, a pharmacy technician discovered 57 vials of the Moderna vaccine. The vials were returned to the refrigerator and the technician reported it to superiors.
How did Aurora come to realize they were intentionally, not accidentally, removed?
After discovering the vials were left out, Aurora began its own investigation and over the next few days the company became “suspicious” of the pharmacist and he was suspended.
After several interviews, the individual admitted Wednesday to “intentionally removing the vaccine from refrigeration.”
What’s the timeline of the vaccine doses being removed?
OVERNIGHT, CHRISTMAS EVE TO CHRISTMAS
Pharmacist removes the vaccine from refrigeration overnight Christmas Eve and then returns it to the fridge Christmas morning.
STARTING EARLY MORNING, SATURDAY, DEC. 26
Pharmacy technician discovers 57 vials of vaccine outside the refrigerator. The vials are returned to the refrigerator, and the technician reports it to superiors.
The pharmacist responsible for removing the vials says it was an “inadvertent error,” the result of accessing other items in the refrigerator.
“In the subsequent hours” (still Saturday, Dec. 26), clinical leaders confer and decide the vaccine can still be administered that morning, because the Moderna vaccine is good for 12 hours after being removed from refrigeration.
Fifty-seven doses are delivered before leaders determine the vaccine has been out for 12 hours and was “rendered ineffective.”
Unknown to them, these doses were already ruined a day earlier, the night of Christmas Eve through Christmas morning.
“SUBSEQUENT” DAYS
Internal review causes Aurora to become “increasingly suspicious” of the pharmacist.
The pharmacist is suspended and interviewed “multiple” times.
MONDAY, DEC. 28
Aurora announces that more than 500 doses had to be discarded because of “human error.”
WEDNESDAY, DEC. 30
The pharmacist admits “intentionally removing the vaccine from refrigeration” — both the removal that was discovered Saturday, Dec. 26, and removing and returning the vaccine to the refrigerator overnight on Christmas Eve.
Are there any concerns that the employee previously tampered with any vaccination-related efforts?
According to Aurora, there is no other evidence to suggest any other doses of vaccine were subject to tampering.
How much of Aurora’s vaccine supply was ruined? Was this the hospital’s whole inventory at the time?
Aurora said this hospital had not gotten vials of the vaccine before Dec. 24 and documentation protocols helped identify when the vaccine arrived at the campus and when the individual would have had access to the vaccine and “are confident” no other vaccine vials were affected.
Aurora added they were able to get other vials of the vaccine from other sites within their system. Vaccination will continue as planned at the facility in Grafton.
What is going to happen to the 57 people who received the damaged vaccine?
Aurora said individuals who received the vaccine from the tampered vials have been notified and the company is working with Moderna and the FDA on a strategy to properly vaccinate those individuals.
Moderna has told Aurora there are no negative effects of receiving vaccines that were rendered ineffective.
What does Aurora plan to do to keep future vaccines it receives safe and secure?
It’s unclear if anything will change at Aurora. During the press conference, Bahr said Aurora is reviewing their processes to identify gaps that led to this incident and they believe this is a situation involving a “bad actor” as opposed to a bad process. The company believes it process are sound.
What will happen next in this case/investigation?
Law enforcement plans to move forward with formal charges.