OHSU

Information about the USDA’s investigation into the 2009 monkey escape at the OHSU primate center and other events 

On August 21, 2012 the United States Department of Agriculture announced that it had fined Oregon Health & Science University $11,679 following their investigation of four incidents in 2009.
Those events were:

  • The escape of 9 monkeys in April 2009, an event that received local and national news coverage. Only two of the animals left OHSU property during the event.  At the conclusion, all animals were captured and accounted for.
  • The death of an animal that received a sedative at a dose higher than typically prescribed.
  • The death of two animals related to the malfunction of a drinking apparatus.
  • The death of two animals following the injection of a compound with a high toxicity level based on a miscommunication

All of the events that were investigated were previously self-reported to the federal government by OHSU at the time of occurrence. OHSU will pay the full amount of the USDA fine. However more importantly, OHSU has adjusted procedures and policies. OHSU has also updated animal care facilities aimed at preventing similar incidents.

“Our goal at the Oregon National Primate Research Center is to seek a balance. We need to advance human and animal health through the use of animal studies when necessary, while at the same time ensuring the health and well being of all our animals,” said Nancy Haigwood, Ph.D., director of the Oregon National Primate Research Center.  “These incidents are unfortunate and the animal losses were felt deeply by our staff. The personal impacts of these incidents on our veterinarians, animal caregivers and scientists far outweigh any fine.” 

“However, these incidents do highlight that strong federal and university controls are in place to take action when unexpected incidents occur. In addition, these events highlight OHSU’s constant efforts to evolve and improve animal care. In each case, OHSU’s response was immediate and thorough. OHSU’s primate center seeks to eliminate errors whenever possible."

Details on the incidents investigated by the USDA
Because the USDA’s press release and documentation on their investigation is limited, we are summarizing both the incidents and OHSU’s response below.

Animal Escape from ONPRC

Summary
The escape of 9 monkeys from their ONPRC enclosure in April 2009 is widely known and received significant press coverage at that time. This public awareness is due to the fact that OHSU alerted the public/press when the animals escaped on Friday April 3. The animals got out of their enclosure because an employee who was cleaning an outdoor group housing structure failed to engage a door lock when exiting. Typically, escapes are incredibly rare and animals often remain close to their living environments until captured. In this case, on-scene staff attempted to assist in rapidly capturing the monkeys. Four of the animals were captured immediately.  Four additional animals were captured on Saturday April 4, including one captured at an apartment complex next door to the primate center. On Sunday April 5, the final animal was captured on the ONPRC campus after it briefly crossed the fence onto the adjoining Oregon Graduate Institute Campus. In addition to alerting the press, OHSU proactively reported federal authorities to this incident.

OHSU's response: 

  • OHSU immediately built secondary fence around the enclosure where the escape occurred.
  • The primate center formed a specialized team of animal care employees with expertise in capturing animals if there is another incident in the future. (There has not been another incident to date)
  • OHSU constructed a new fence surrounding the entire 165-acre primate center campus. The new fence, which replaces a standard perimeter fence, is higher and built out of a material that is more difficult for monkeys to climb. 
  • OHSU trimmed all vegetation near the fence to help ensure animals remain on the property if they were to get out of their primary enclosures.

Death of an animal receiving veterinary care

Summary
The USDA conducted an investigation following the unexpected death of an animal in July 2009. The animal died after receiving a sedative that was part of the research being conducted. Following treatment, the animal was placed in its cage where it died during the night. The cause of the animal’s death was found to be human error. The technician mistakenly provided the animal with a dose of sedative normally given to an animal with higher tolerance to the drug. However in this case, this was the first time the animal received the sedative and therefore the dosage, while within the parameters of the study, was higher than advised for an animal’s first dosage. OHSU proactively reported the incident to federal authorities.

OHSU's response:

  • The employee was retrained on the proper use of animal sedation. This training occurred prior to additional work with animals.
  • All animal care staff received additional training on animal monitoring to ensure that animals are responding to medications appropriately.
  • The National Institute of Health’s Office of Laboratory Animal Welfare (OLAW) reviewed the matter and found that the remedial steps were appropriate.

Malfunction of a drinking water apparatus resulting in two animal deaths

Summary

In November 2009, employees conducting daily health checks of animals found three monkeys showing signs of dehydration. The animals were immediately taken to the ONPRC’s onsite health clinic for treatment. One animal fully recovered while another animal expired. Veterinarians decided that the third animal should be humanely euthanized. A subsequent investigation revealed that a newly installed drinking apparatus which is designed to allow animals 24/7 access to water had malfunctioned leading to the three cases of dehydration. OHSU proactively reported the incident to federal authorities.

OHSU's response:

  • All drinking water lines at ONPRC were checked immediately to make sure they were operational (they were)
  • A new procedure was put in place to make sure that the water lines are tested as part of animal care daily rounds to check on and feed animals.
  • The National Institute of Health’s Office of Animal Laboratory Welfare reviewed the matter and found that OHSU response at the time was appropriate.

Mistaken medication given to two animals

Summary
In May 2009, two animals died (one died, one was euthanized) after they were given a drug based on mistaken understanding. The compound is typically used to identify newly formed blood vessels while conducting health research. Research staff had suggested using the compound based on previous experience working with tissue obtained from euthanized mice. The compound was not designed for living animals because of its toxicity level. Because of this misunderstanding two animals were lost. The OHSU panel charged with overseeing animal research had not previously approved use of this specific compound in monkeys as is required before all research actions.  OHSU self-reported the incident.

OHSU's response:

  • The research staff involved in the matter were retrained on the use of toxic agents
  • The scientists were required to develop a clear communication plan to ensure a mistake like this is not repeated.
  • The National Institute of Health’s Office of Animal Laboratory Welfare reviewed the matter and found that OHSU response at the time was appropriate.

Mutimedia

Link to photos of ONPRC’s new external fence

Downloadable B-roll of ONPRC’s new external fence

Link to photos of additional fencing around animal housing following the 2009 escape

Downloadable B-roll of additional fencing around animal housing following the 2009 escape

Downloadable B-roll of Monkeys ONPRC