A man is holding an insulin pen aloft.
Insulin pens are meant for single-patient use. (Photo Credit: CC BY/Alexandre Normand/Flickr)

A registered nurse who worked in various Wisconsin health clinics since 2006 has inadvertently exposed as many as 2,345 patients to blood-borne diseases such as Hepatitis B, Hepatitis C and HIV, Reuters reports. Health officials and all patients seen by the diabetic education certified nurse over the past five years at various Dane County clinic locations have been notified.

Risk level low, but all precautions taken

Dean Clinic CEO Dr. Craig Samitt told Reuters via telephone that the Madison-based chain of 60 clinics takes this matter seriously.

“We are taking all precautionary steps to test all of the patients even though the risk level is low,” he said. “(We’re) casting the net as broadly as we possibly can.”

Stephanie Smiley, a spokeswoman for the Wisconsin Department of Health Services, underscored via email to the Associated Press the need for more testing.

“This is a very serious situation, and it appears that Dean Clinic is taking the appropriate steps to notify patients of possible exposure and performing follow-up testing as necessary,” she wrote.

The nurse in question held the proper credentials to demonstrate to diabetic patients how to use an insulin pen and finger stick device in the process of managing their blood sugar levels. The nurse changed needles between patients, but she shared the same devices between patients. Medical research suggests that despite a needle change, blood accumulation can adhere to the device.

In addition, the nurse used insulin pens on live patients, which is improper procedure. These devices are intended for use on objects like oranges, for illustrative purposes.

‘A personnel matter’

Samitt noted that the nurse left her Dean Clinic job on Aug. 10 but declined to reveal further details, calling it “a personnel matter” and an isolated incident. It is unclear why the nurse, who was experienced, deviated from clinic procedure. The Associated Press reports that Dean Clinic worker retraining in the use of insulin pens and related practices is in progress.

FDA has known about danger of insulin pen since 2009

The U.S. Food and Drug Administration observed that some health care providers were sharing insulin pens between patients in 2009. The risk of pathogen transmission was identified, and the FDA made it clear that the devices should be single-patient use only.

“Insulin pens are designed to be safe for one patient to use one pen multiple times with a new, fresh needle for each injection,” said Dr. Amy Egan of the FDA’s Division of Metabolism and Endocrinology Products in the Center for Drug Evaluation and Research. “Insulin pens are not designed, and are not safe, for one pen to be used by more than one patient, even if needles are changed between patients due to the risk of transmitting blood-borne pathogens.”

Why insulin pens shouldn’t be shared


Associated Press: http://bit.ly/o3YTi7

Reuters: http://www.reuters.com/article/2011/08/29/us-wisconsin-clinic-idUSTRE77S5WJ20110829

U.S. Food and Drug Administration: http://1.usa.gov/cHVIxY

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