53 share a needle & HIV risk due to a clinic blunder

By Dr. Ananya Mandal, MDFeb 13 2011

Over 50 patients at a private radiology clinic were given blood tests using a needle device meant for single-patient use. Authorities have launched an investigation into the matter. These patients are all at risk of hepatitis B, hepatitis C and HIV infection. These cancer patients will need testing for the viruses, and again in three months. They had visited the hospital for a positron emission tomography (PET) scan for cancer detection.

The clinic that did the mix up is on the NSW central coast, PRP Diagnostic Imaging. They released a statement saying that authorities at the clinic have written to affected patients to apologise for the mistake, which was discovered two weeks ago.

They began blood glucose checks in December using the Accu-Chek Multiclix device, which fires a spring-loaded needle into a finger to produce a drop of blood. Michael Jones, the chairman of PRP, which runs 17 clinics in NSW, said the device was in use only at the Gosford clinic.

The nurse who administered the test mistakenly believed that the device automatically changed needles. She did not know that she had to change the needles manually. Instead, the needle was left unchanged between November 28 and January 28, and used on 53 patients and two staff members. The error was found when a staff member with diabetes asked the nurse to perform the test on her and discovered the incorrect usage, Dr Jones said. He said, “Unfortunately, the device that we’ve used, there was a misunderstanding about the suitability and operation of the pin-prick device, the result of which was that the same needle was used repeatedly on several people over two months… The moment we found out, we withdrew it from service.”

Dr. Jones, after consultation with an infectious disease specialist said risk of infection was “low or very low”. He said the clinic was “extremely disappointed” by the incident and the nurse involved was “shattered”. The nurse, staff and cancer patients involved would be offered support and counselling, he said. “We’re deeply apologetic that this episode in their journey is just another problem for them to cope with,” he said.

A spokeswoman for the Therapeutic Goods Administration revealed that the TGA is working with NSW Health authorities to urgently investigate the matter. Katherine McGrath, the chief executive of the Australian Association of Pathology Practices, said the episode illustrated the “dangers” of the push for more point-of-care testing.