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.
"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."