“OHSU is a health and research university dedicated to improving the health and well-being of people in Oregon and beyond. Biomedical research conducted at OHSU using relevant animal models is essential to developing new ways to identify, prevent, treat or eliminate disease, and to improve human and animal health. Our views on this reflect those of other academic health centers, universities, physicians and scientists worldwide.  

We deeply regret the accidental death of a nonhuman primate that was critically injured when an enclosure door unexpectedly closed. Following a thorough root cause analysis and investigation, we have taken steps to prevent a recurrence. While the unpredictable behaviors of undomesticated animals are impossible to completely eliminate, OHSU strives to do everything in its power to employ best practices in engineering, training and supervision to protect against them. 

Dozens of highly trained veterinarians, technicians and support personnel engage with research animals at OHSU daily to ensure their ongoing safety, enrichment, health and well-being. Many staff members develop strong bonds with the animals entrusted to their care; consequently, any injuries or unexpected deaths are devastating for all involved. The animal technicians and other OHSU members impacted by this accident have been offered wellness resources and support options available through OHSU’s Well-Being Program. 

Serious accidents or incidents involving research animals at OHSU are immediately reported to the university’s Research Integrity Office, which investigates and reports to OHSU’s Institutional Official and Institutional Animal Care and Use Committee, who then ensures appropriate measures are taken to prevent a recurrence. 

OHSU promptly reports any serious issue or incident to the NIH’s Office of Laboratory Animal Welfare, whose highly trained veterinary staff thoroughly review OHSU’s mitigation response to determine whether it is complete and appropriate, thereby ensuring that OHSU has done everything possible to minimize the possibility of it happening again.” 

BACKGROUND 

On May 4, 2023, during a routine capture of a female rhesus macaque and her infant, the female monkey aggressively charged the doorway, allowing the vertical slide door to fall. At that moment, the infant either fell from the female’s grasp or the female dropped it, and the vertical slide door impacted and injured the infant.  

The animal was immediately transferred to the ONPRC hospital, examined by veterinary staff and humanely euthanized. The female was admitted to the hospital and examined, but no injuries from the incident were observed.   

The attending veterinarian notified OHSU’s Institutional Official, the Chair of the Institutional Animal Care and Use Committee, or IACUC, and the Animal Care and Use Program, or ACUP, director, and an internal root cause analysis was initiated, per ONPRC standard practice. The ACUP Director and IACUC chair initiated an independent investigation that included private interviews with the animal care technicians, the veterinarians who examined the animals, and the training coordinator. 

The results of the root cause analysis and independent investigation were reported to the convened IACUC, and after careful and thorough consideration, the committee determined the incident was an accident resulting from the physical characteristics of the transfer box and the door. It was determined that the accident was not due to human error as the standard operating procedure, or SOP, had been followed by the animal care technicians.  Rather, the animal reacted in an unanticipated manner that had not occurred previously.  

Although this capture technique has been used for more than 10 years without incident, the root cause of the accident was identified as the ability of the vertical slide door to fully close if the transfer box became dislodged. Consequently, the IACUC voted unanimously to approve the following actions to prevent recurrence: 

• Effective immediately following the accident, two trained persons are required when the box and vertical slide technique is used for cooperative capture. One person must stand outside the enclosure and manually operate the pulley and cable system that controls the door. If two trained people are not available, other capture techniques must be employed. 
   
• The standard operating procedure, or SOP, and training will be updated to include the requirement for a second individual to manually operate the slide pulley and cable system from outside the enclosure. The IACUC will review these revisions. 
   
• An engineering solution must be installed before a second person will no longer be required to manually operate the vertical slide pulley and cable system. The engineering solution must prevent the vertical slide from fully closing, even if the transfer box is dislodged. Regular updates on the design and implementation of an engineering solution will be reported to the IACUC. 

As is standard practice, OHSU promptly reported the accident, the results of the analysis and investigation, and the university’s mitigation plan to the NIH’s Office of National Laboratory Welfare. This information was transparently and proactively shared with OHSU members and posted on our public news site.