Training failure blamed for monkey deaths at OHSU center
An internal investigation by OHSU found that an animal care technician's failure to follow written procedures led to the deaths of two monkeys this past summer at the university's Oregon National Primate Research Center in Hillsboro.
The investigation also concluded that the university's trainers had not confirmed the technician's competency with procedures through a proficiency assessment prior to the incident, OHSU said in a statement Nov. 18.
An internal committee "determined that more robust training and supervision, in addition to more thorough monitoring of the training program by the committee, might have prevented the tragic incident," OHSU said.
The research center continues to face scrutiny by animal rights groups, which have filed and amended multiple recent complaints against OHSU related to animal experimentation.
The deaths of two rhesus macaques on Aug. 13 prompted animal rights group Stop Animal Exploitation NOW! (SAEN) to file a complaint with the U.S. Department of Agriculture's division overseeing animal welfare.
The deaths occurred when an animal care technician placed a 6-foot-tall rack of monkey cages into a cage-washing machine and turned it on without realizing there were still two monkeys locked in one of the top cages, OHSU said in a statement Aug. 28.
Following the incident, OHSU's institutional animal care and use committee convened a subcommittee to investigate the incident. The subcommittee interviewed 21 people with direct knowledge of events related to the incident and reviewed operating procedures and training records, OHSU said.
The investigation found that the technician mistook a clean rack of cages, where the monkeys had been previously placed, for a dirty rack before placing the clean rack containing the monkeys in the cage washer, OHSU said. The cage washer uses high temperatures to clean the cages.
The technician left the room, noticed the mistake and stopped the cage washer.
Veterinarians were alerted and responded to the cage washing area within two minutes, OHSU said.
"One of the monkeys had passed away by the time the veterinarians entered the building," the university's statement on the investigation reads in part. "The second monkey survived the incident without showing outward signs of the trauma and veterinary staff quickly anesthetized the animal, initiated treatments for shock and heat stress, and began a thorough physical examination.
"As the examination and treatments continued, tissue damage became apparent. Prior to allowing the animal to regain consciousness, veterinarians humanely euthanized the animal."
The university said the technician had been trained for six weeks in a different cage sanitation area but was trained for only two days in the area of the incident.
It was the technician's first time working independently in the area where the incident happened, OHSU said.
Standard operating procedures, cage design and cage washing equipment differed between the two sanitation areas, OHSU said.
"The trainers judged the technician was prepared to work alone, and the employee agreed, but the trainee's competency through an objective proficiency assessment had not been confirmed," the university stated. "The technician conveyed an understanding of the general standard operating procedure for cage washing, but did not appear to know the differences between procedures for the two cage wash areas. This fatal gap in understanding indicated that the technician was not ready to work alone."
Michael A. Budkie, co-founder and director of SAEN, says the USDA has acknowledged the group's complaint related to the incident, but the agency hasn't provided any other information.
The complaint asserts that the incident is a violation of the Animal Welfare Act and calls on the USDA to "conduct a full audit of all animal health care records for OHSU regulated species to allow for a complete prosecution of this career criminal."
"OHSU's admission that the technician was not adequately trained in the cage wash area in which they were working indicates that this situation would violate" the Animal Welfare Act, Budkie said in an email to the Pamplin Media Group on Wednesday, Nov. 25.
OHSU could be fined a maximum of $10,000 per infraction of the Animal Welfare Act, according to the complaint.
"Negligence at OHSU has killed over a dozen animals since 2016, and injured many more," Budkie said. "In this period, this lab has (failed) to follow federal regulations 19 times relevant to regulated species. OHSU's multi-year pattern of negligence demonstrates not only contempt for the law, but an utter inability to perform even basic animal husbandry without killing animals."
The complaint refers to the deaths of 13 other animals from four different species at OHSU facilities since 2016.
People for the Ethical Treatment of Animals, another animal rights group, has been calling on the research center to shut down for years.
OHSU says its research must continue.
"Knowledge gained through biomedical research in relevant animal models is essential to developing new ways to identify, prevent, treat or eradicate disease and to improve human and animal health, including ongoing research into vaccines and treatments for COVID-19," OHSU said in its statement Nov. 18.
The incident has prompted OHSU to make several changes at the research center.
Following the deaths of the monkeys, an attending veterinarian at OHSU immediately stopped the use of automated cage washers and implemented a handwashing protocol, the university said.
A week later, the investigating subcommittee approved the implementation of a two-person verification procedure for slowly restarting the use of the automated cage washers, OHSU said. The procedure currently remains in effect and technicians have been trained to use it.
The cage washer training program has also been revised, OHSU said.
Formal proficiency evaluations in which a trainee must prove competence have been implemented. The evaluations will be reviewed by multiple supervisors, including the attending veterinarian.
The investigating subcommittee has also required that a "robust training and quality control program must be developed and implemented to include regular review of the training program."
Peter Barr-Gillespie, OHSU's chief research officer, has also engaged an external review panel to make recommendations for improvements consistent with best practices at other primate research centers. Its work is expected to take several months.
Budkie still doubts the changes will prevent similar accidents from happening in the future.
"Since the deaths occurred because the existing protocols weren't followed, changing the protocols may not prevent future accidents if those new protocols are also ignored," Budkie said.
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