Wisconsin Clinic Warns of Possible Disease Exposure

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.

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