August 16, 2021
Keio University COVID-19 Task Force
On Wednesday, August 4, 2021, it was discovered that vaccines stored at our university had been lost. Since then, we have been interviewing relevant staff and searching the campus, but the vaccines have not yet been found. We sincerely apologize for the loss of these precious vaccines, which were supplied for our workplace vaccination program.
1. Vaccines Confirmed Lost
Two vials of the Moderna vaccine (20 doses)
2. Background
On Wednesday, August 4, following standard procedures, vaccines were removed from the refrigerator in several batches, dispensed into syringes, and audited. Shortly after 3:00 p.m., a shortage of two vials was noticed, and the loss was discovered.
3. Investigation and Response to Date
Wednesday, August 4, 2021
Staff who entered and exited the preparation room were interviewed.
Wednesday, August 4, and Thursday, August 5, 2021
The inside of the preparation room and waste from the room were inspected by multiple staff members.
As of Monday, August 16, 2021
The investigation is ongoing, but the vaccines have not been found, and the cause has not yet been determined.
4. Preventive Measures
The removal of vaccines from the refrigerator was double-checked and confirmed against the previous day's inventory records. However, the progress of vaccine preparation and post-dispensing management was not tracked in real time. Additionally, although empty vials were numbered, this was done during the post-dispensing audit, which meant the loss of the two vials was not noticed until near the end of the audit. Therefore, the procedures have been changed as follows.
・All vials will be marked immediately upon removal from the refrigerator.
・The numbering of empty vials in groups of five, previously done after the dispensing audit, will now be performed at the time of preparation (before dispensing).
・Preparation and dispensing will be carried out for each identically numbered tray (5 trays, 50 syringes) to ensure accurate progress management.
End