The nurse who surrendered her license after mishandling a flu clinic blames herself - but also the company that sent her the wrong supplies.
The nurse who botched a workplace flu clinic by using just two syringes to inoculate 67 workers last fall says in a written account she say she gave to state officials that her Nebraska-based employer sent the wrong supplies.
In a statement she submitted to the N.J. Board of Nursing when she temporarily surrendered her license, she claims there were several problems with the supplies earmarked for the flu shot clinic held at West Windsor pharmaceutical company:
- The Nebraska-based company that hired her sent her three 10-dose bottles of vaccine instead of individually pre-filled syringes.
- Those bottles amounted to just 30 doses - not nearly enough for the number of employees who had signed up.
- Only two needles were included.
- And they were the wrong kind: the type used for insulin injections. The markings along the barrel were in units of insulin, not in millimeters - and she didn't have the training to convert one measurement to the other.
"I did my best to eyeball what I felt was as near to the appropriate does per client," she said in her first public comments about the episode that made national news. She did use a fresh needle for each patient.
As a result of her imprecision, all the affected employees were advised they needed a second flu shot. More importantly, because the two syringes were re-used after each shot, they were advised they should be tested for any transmission of HIV, and hepatitis B and C.
Roback apologized at the close of her statement, which she said she gave a Board of Nursing representative who interviewed her in her Ewing home a week after the Sept. 30 clinic at Otsuka America Pharmaceutical. Roback provided a copy of the statement to NJ Advance Media.
"I am a caring nurse and would not intentionally do anything that would be harmful to anyone I treat. I am cognizant that what I did led to harmful effects on the clients I provided vaccine to...for which I am truly sorry," she wrote in her statement.
The company that hired her online is TotalWellness, based in Omaha.
Companies pay TotalWellness to run flu vaccine clinics or biometric screening at their worksites. TotalWellness staffs those clinics with an army of 6,000 healthcare providers who are paid on a per-clinic basis.
Contacted about Roback's claim she received the wrong supplies, a spokeswoman for TotalWellness said, "There is an ongoing investigation regarding this matter, and therefore we cannot comment."
When the mishandled clinic came to light, TotalWellness issued a statement indicating, "Our sincerest apologies go out to all those affected by this terrible event."
The 67 Otsuka employees who received a shot at the problematic clinic were offered free blood tests on the chance that blood from one employee might have been transferred to a coworker because of the repeat use of the syringe.
The workplace clinic was halted when an employee complained about a syringe being reused. Otsuka personnel contacted TotalWellness, which notified the N.J. Department of Health about the breach of injection protocol.
So far there have been no cases of disease spread by Roback's shots, according to a spokeswoman for the N.J. Department of Health. There is still one more round of testing as well as the third and final round of Hep B vaccination scheduled for this month before employees will know they're in the clear.
TotalWellness contracted with Roback to administer flu shots at three area clinics last fall, the LPN said. When a shipment of the supplies for each clinic arrived at her apartment, she would mark the Styrofoam cooler containing the vaccine with the name and date of the clinic, then place it in her refrigerator, she said.
She would then print out the event work sheet and tape it to the box of clinic supplies - vials, syringes, gloves, etc. - designated for each clinic.
When she unpacked the equipment once at Otsuka, however, she said she was surprised to see there were just three vials of vaccine - not nearly enough for the number of sign-ups - and only two syringes.
Despite that setback, she went ahead with the clinic - a decision she says she regrets.
She said she didn't abruptly cancel it in part because she needed the money, but mostly because Otsuka had gone to a lot of trouble to get her through security and set up the clinic. Instead, she said she decided to "make do with what I had."
"I guess I didn't want to make a scene of saying, 'Hey, I don't have the right stuff. I can't do this,'" she said."I needed to be paid. I wasn't working. I figured even if it was only $125, I'd get that out of it. So it was somewhat selfish of me."
When state health officials contacted her about her errors, she agreed to surrender her nursing license temporarily. The Board of Nursing has not yet rendered a final decision about her.
Roback said that in addition to attaching a fresh needle for each shot, she cleaned the hub and barrel of the syringe with a new alcohol prep pad after cleaning her hands with sanitizer.
In her statement, she said she did not aspirate with each injection. That's the technique of inserting the needle, then drawing up on the plunger a little to see if any blood appears - a sign the needle has hit a vein or artery and should be repositioned.
Ironically her failure to aspirate reduced the likelihood that blood from one vaccine recipient would come in contact with the next person getting a shot.
Once complaints about her clinic reached TotalWellness, they canceled her contract for the next two clinics - one of which was scheduled to be at Nestle - and told her to return the vaccine and other supplies.
Since then, Roback, 63, has been looking for work and fighting eviction from her apartment. She can't afford to hire an attorney to represent her in any Board of Nursing proceedings, and seems resigned to losing her LPN license.
She also has a master's degree in health administration and was employed for over a year by an Essex County family to provide specialized therapy to their 23-year-old autistic son. Under her tutelage, she said, he finally learned how to tie his shoes.
Roback said she has learned her lesson. In the section of her statement titled, "What I should have done differently," she wrote, "Never/ever, re-use a syringe when giving any type of injection."
Kathleen O'Brien may be reached at kobrien@njadvancemedia.com. Follow her on Twitter @OBrienLedger. Find NJ.com on Facebook.