Associated Press (08.29.11) - Tuesday, August 30, 2011
The Madison-based Dean Clinic announced Monday that it is
seeking to contact 2,345 patients to advise they get tested
for HIV and hepatitis B and C. Between 2006 and two weeks ago,
a nurse employed by the clinic was improperly reusing insulin
demonstration pens and finger-stick (lancet) devices during
the training of newly diagnosed diabetics, the clinic said.
A fellow employee alerted Dean Clinic to the problem earlier
in August. An internal investigation found the nurse used
clean needles but the same pen each time on patients. However,
even a microscopic amount of blood backflow could endanger the
next patient if the pen itself is reused. The finger-stick
device is also supposed to be used on only one patient. The
nurse changed to new needles from patient to patient while
reusing the device's handle, which poses an infection risk.
The nurse left on Aug. 10, the same week clinic officials were
alerted. Nonetheless, the nurse was certified as a diabetic
educator, so it is unclear why device guidelines and clinic
protocols were not followed, said CEO Dr. Craig Samitt and Dr.
Mark Kaufman, the clinic's chief medical officer. The nurse
was supposed to have been demonstrating the devices on an
orange or pillow, Kaufman said, not on patients themselves.
Samitt would not say whether she resigned or was terminated.
The clinic has about 720 health care providers located in
southern Wisconsin. Samitt declined to identify where the
nurse worked. State and local health officials have been
notified and are monitoring the situation. No one had detected
any clinic-related infections as of Monday, when Dean Clinic
began contacting patients by telephone and mail.
"This is an ongoing investigation," Samitt said. A CDC
spokesperson had no immediate comment.