Review of discarded vaccines details lax oversight by Knox County Health Department

Local News

KNOXVILLE, Tenn. (WATE) — An independent review of the Knox County Health Department ordered after a box of COVID-19 vaccines was lost has now been released. The 975 Pfizer COVID-19 vaccine doses were accidentally tossed out in February just as the shots were starting to reach the public.

Outside accounting firm Pugh and Company released a five-page report after talking with workers and reviewing how the department’s processes work.

The report shows issues like a lack of written procedures in shipping, receiving and keeping track of inventory and supplies. Pugh & Company found that one employee was responsible for ordering vaccines with no approval. The same employee was also tasked with receiving the shipments.

It notes the department did have some common practices, but they weren’t written down. Limited-cross training for operations workers was also noted in the report, creating the potential for issues to occur if the worker usually in charge of a certain task is not present.

More issues include a lack of controls to prevent unauthorized pharmacy orders and weak physical security around the loading dock. A lack of written procedures related to shipping, receiving, and inventory were also noted in the report.

Knox County government released its own investigation’s findings March 11 in which no criminal activity was found. The Knoxville Police Department’s report showed that an employee signed for the vaccine but never saw it. A second employee ordered the box containing the vaccine to be thrown away after they inspected it and thought it only contained dry ice.

A statement from the Health Department following the review said it has already begun to implement some of the recommendations by Pugh & Company. The statement also notes the department conducted its own extensive review of internal processes and implemented changes, including the creation of uniform processes to receive items, communicating processes with team members and ensuring cross training is taking place.

We are grateful for Pugh’s expertise and believe the findings included in the report are helpful. We have already begun to implement them within the Health Department. It’s important to note that immediately upon learning of the error and prior to the engagement of Pugh to conduct their audit, KCHD immediately conducted an extensive review of internal processes and implemented changes. We will proceed with a strong focus on continuous quality improvement to best serve the people of Knox County.


As previously stated, KCHD conducted a robust internal review of processes immediately upon identifying the issue and has since implemented changes. We want to note that the volume of vaccine and the pace at which it was coming during this time was unlike anything the Health Department and the country had seen before. The system to receive this vaccine was stressed and therefore an unfortunate mistake was made. The following measures are a few of what we have put in place since then based on our internal review: Adding a pharmacist to assist with vaccine management, the creation of a team built specifically to oversee vaccine management, the designation of a documented receiving system with redundancies for all three vaccines, and the development of a new nomenclature and tracking system.


We received the final report from Pugh this week. As you can see in the audit, its scope is broader than vaccine management and looks at the larger operation of supply chain management. Some of what was detailed in the report mirrors our own findings. Prior to receiving Pugh’s report, KCHD began working with each division within the Health Department on a variety of procedural improvements related to documentation, inventory and internal controls. This includes the creation of uniform processes to receive items, communicating these processes to team members, and ensuring cross training is taking place. Additionally, we reduced access surrounding our Building Operations area. KCHD is also working in coordination with other county departments to ensure a streamlined and coordinated supply chain management approach.

Knox County Health Department on the Pugh & Company review

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