UPDATE: State Concludes Investigation into Diabetes Nurse Educator Incident

UPDATED: Wednesday, August 22, 2012 --- 7:41p.m.

Release from Dean Clinic:

Madison, Wis. – In August 2011, Dean Clinic announced it had become aware that one of its diabetes nurse educators had potentially been misusing needle stick devices and insulin demonstration pens. Dean chose to contact each patient who may have had contact with the employee.

Dean cooperated with the Department of Health Services, Division of Public Health (DPH), interviewing nearly all identified patients and testing those patients Dean believed could have been put at risk of blood borne pathogen exposure.

Recently, the Division of Public Health issued its final report to Dean on the incident. In the report, DPH found no evidence of transmission of HIV, Hepatitis B or Hepatitis C associated with this incident.

Due to natural prevalence rates of disease (evidenced by the Centers for Disease Control, or CDC) among random populations, it was anticipated there may be positive results unrelated to the incident. Results found were lower than natural prevalence rates nationwide, however, once again, DPH found no evidence of transmission of HIV, Hepatitis B or Hepatitis C associated with this incident.

The Division of Public Health conducted an epidemiologic investigation, reviewing medical records including the dates of visits/appointments, clinic location of visits and whether an insulin or lancet device pen was used.

“Patient safety and compassionate care are foremost priorities for Dean Clinic,” says Dr. Craig Samitt, President & CEO of Dean Clinic. “Immediately following the incident, our patient care staff members and providers completed an educational review of proper bloodborne pathogen safety training.”

“Dean Clinic also mandates ongoing skills training to ensure staff competency on core clinical skills,” says Brenda Klahn, Dean’s Community Exposure Specialist. “We have enhanced our auditing process for the handling of medical devices and adherence to policies and procedures in our nursing and clinical areas.”

Given the prevalence of bloodborne pathogens in adult populations, in May of this year, the CDC issued a recommendation to all baby boomers born between 1945 and 1965. The CDC encouraged baby boomers to be tested for Hepatitis C because many are unaware that they carry the disease.


UPDATED Thursday, February 23, 2012 --- 6:30 a.m.

MADISON, Wis. (AP) -- A man who says he contracted hepatitis C from a nurse educator is suing Dean Health System in Dane County Circuit Court.

Keith Steffen's lawsuit comes after Dean Health officials announced that the diabetes nurse educator may have exposed nearly 2,400 patients to hepatitis C by mistakenly reusing insulin demonstration pens and finger stick devices.

The lawsuit filed by the 55-year-old Monona man says he contracted the disease as a direct result of the mistake. Dean officials say the nurse no longer works for the health care provider.

The State Journal (http://bit.ly/yvbaFZ ) says the state Board of Nursing is expected to consider disciplining the nurse at a meeting Thursday.


Information from: Wisconsin State Journal, http://www.madison.com/wsj

Copyright 2012. The Associated Press.


UPDATED: Monday, August 29, 2011 --- 2:15 p.m.
REPORTER: Chris Woodard

According to officials at Dean Clinic this would not be isolated to a specific clinic. It involves one former employee who was a diabetic nurse educator. This former employee saw diabetic patients from throughout the Dean Clinic System. Dean CEO Craig Samitt says they will not release the name of the former employee.

The investigation began when a fellow employee raised concerns.

This former employee was inappropriately using insulin demonstration pens and a finger stick devices.

Chief Medical Officer Mark Kaufman says this former employee was changing needles but reusing the rest of the device.

Kaufman adds, "When the needle enters a patients finger it's possible a small amount of blood may travel up back through the needle, flash back into the sterile saline and stay there. Even if the needle is then switched for another patient there is a theoretical possibility that the blood in the sterile saline, microscopic as it is, could cross contaminate and go into the second patient."

Furthermore Kaufman says, "The insulin demonstration pen is intended not to be used on a person. It's intended to be a demonstration device used on an inanimate object such as a pillow or an orange to demonstrate insulin."

The finger stick devices are also only supposed to be used on one person.

Kaufman says, "That blood would have to be splashed up at the point of entry of the lancet and somehow get on the base of the instrument. Lancets are then changed but if there is residual blood still there at the base of the holder it's theoretically possible that could cross contaminate and transmit a virus."

The Clinic is now reaching out to all 2,345 patients that had visits with the former diabetic nurse educator.

Letters have been sent out and they're beginning phone calls today.

Samitt says, "We're hoping that the risk level is very low given the circumstances we've identified in the investigation but we want to be precautionary and want to test everyone."

Samitt adds, "Communicating freely and transparently about this incident is critical to us. If there is a patient that may have been effected we want to make sure they're tested and do whatever it takes to take good care of them."

Following is a statement from John Murray, Executive Assistant at the Department of Safety & Professional Services:

The Department of Safety & Professional Services (DSPS) received information today from the Dean Clinic in Madison regarding a series of incidents alleging unsafe practices by one of their former employees. We will be reviewing the information. There will be no further comment at this time as it is a pending matter.


UPDATED Monday, August 29, 2011 --- 1:15 p.m.
Posted Monday, August 29, 2011 --- Noon

From the Associated Press: A Madison-based clinic says a former employee may have exposed hundreds of patients to blood-borne diseases such as HIV.

Dean Clinic issued a statement Monday saying the former worker inappropriately used insulin demonstration pens and finger stick devices while training patients between 2006 and this year. The clinic says it is contacting 2,345 patients by phone and letter and will take responsibility for testing them to see if they've been exposed to any diseases.

The clinic says it has notified state and local health officials. A spokeswoman for the clinic didn't immediately return a message.

From NBC15's Chris Woodard: The employee worked at several Dean Clinic facilities, so there isn't one specific Clinic that is dealing with this issue.

Here is the statement from Dean Clinic:

Madison, WI - Dean Clinic has notified state and local health officials that we are investigating the inappropriate use of insulin demonstration pens and finger stick devices during patient training.

An internal review found that a former Dean Clinic employee was inappropriately using these devices during some patient visits between 2006 and 2011.

Therefore, there is the potential that patients were exposed to bloodborne diseases (Hepatitis B, Hepatitis C and HIV).

Patient safety and compassionate care are foremost priorities for Dean Clinic, which is why we take this incident very seriously and will be collaborating with state and local health officials every step of the way.

As a result of our investigation, we are contacting 2,345 patients to determine whether they may have been exposed. These patients will be receiving phone calls and letters from us. We have a team ready to answer patients’ questions. We will also take responsibility for needed testing, we will coordinate follow-up care and support patients’ needs.

“Dean Clinic is committed to supporting our patients. There is nothing more important to us than the health, well-being and safety of the people we serve,” said President and CEO of Dean Clinic Craig Samitt, M.D. “Our goal is to ensure that those who may have been affected by the inappropriate use are promptly informed, tested and supported.”

We have conducted an investigation and have identified this as an isolated incident. As a commitment to our patients, we are re-educating patient care staff on the proper use of these types of devices, enhancing our auditing and monitoring procedures related to these devices and improving our process for routinely observing the clinical practices of our staff.

We will provide updates as additional information becomes available.