Wis. Clinic Warns
Patients of Possible
Blood-Borne Disease
Exposure
By MIKAELA CONLEY
Aug. 30, 2011
A Madison, Wis., clinic
is contacting 2,345 of
its diabetic patients to
determine whether a
nurse may have exposed
them to blood-borne
illnesses, including HIV
and Hepatitis B and C,
over the past five
years.
"An internal review
found that a former Dean
Clinic employee was
inappropriately using
these devices during
some patient visits
between 2006 and 2011,"
the clinic said in a
statement.
In teaching patients how
to administer finger
sticks and insulin shots
to themselves, the nurse
changed the needle with
each patient but reused
the rest of the device,
which could put patients
at a slight risk of
blood transfer from one
person to another. The
practice devices she
used were not even
intended for to be tried
on people, the hospital
said.
"That demonstration pen
is intended to be used
not on people but rather
into an inanimate
object, such as a pillow
or an orange," Dr. Mark
Kaufman, Dean's chief
medical officer, told
ABC's affiliate WKOW.
The clinic, which is
part of a larger medical
system in southern
Wisconsin, reported that
each patient who
received insulin
training by this nurse
would receive a phone
call or letter
explaining the
wrongdoing. The hospital
said it would provide
the necessary blood
tests, follow-up care
and support free of
charge.
"Our goal is to ensure
that those who may have
been affected by the
inappropriate use are
promptly informed,
tested and supported,"
Dr. Craig Samitt,
president and CEO of
Dean Clinic, said in the
hospital's statement.
Administrators plan to
re-educate staff on the
proper use of the
devices, and to change
the way clinical staff
is monitored.
Nurse's Actions Spark
HIV Scare
"This is not going to
herald a huge increase
in communicable diseases
in this population, but
most will suffer more
from the anxiety
associated with the
possibility of exposure
after hearing from the
clinic," said Dr.
Richard Cook, associate
professor of anesthesia
and critical care at
University of Chicago.
"I don't believe this
nurse was cognizant of
the possibility that the
device was a potential
source of infection, but
we know, of course, that
you have to treat these
entire device systems as
contaminated after they
are used," Cook said.
While the risk of
infection appears small,
Dr. Peter Pronovost,
director of John
Hopkins' Armstrong
Institute for Patient
Safety and Quality, said
the hospital should be
commended for handling
the scandal in a "very
forthright and
appropriate" manner, and
emphasized that safety
policies cannot stop at
the top.
Clinicians, he said,
must understand
guidelines at a
practical level, and
policymakers need to
make sure that rules are
clear, unambiguous and
can be carried out by
all.
Device manufacturers,
Pronovost said, need to
be more of aware of
"real world usability"
when creating products
and enclose specific,
practical instructions
on how to use the device
safely.
"The company could
literally put in bold
letters, 'Do not use on
more than one person,'"
Pronovost said. Or in
this case, do not use on
people at all.
"Companies can sometimes
figure out ways so that
it is physically
impossible to make a
fatal mistake with their
products. They can test
where humans can get it
wrong. Humans are
fallible."
http://abcnews.go.com/Health/clinic-infected-thousands-patients-bloodborne-illnesses/story?id=14412542
More information on
finger stick devices
CDC 2004- Finger Stick
Device Lancets
