About 160 syringes reused at Minn. clinic; nurse practitioner fired
ST. PAUL—Liz Lightfoot was in a work meeting when she got a phone call from Allina Health. She wasn't expecting the call and wondered if she'd missed a bill payment or — worse — was receiving bad news from a dermatology appointment last year.
Instead, Allina informed Lightfoot that a nurse practitioner at a dermatology clinic at Bandana Square in St. Paul had reused a syringe — but not the needle — during an injection on Lightfoot during a recent appointment. The health care system told Lightfoot that she should be tested for HIV and hepatitis.
Lightfoot was one of 161 Allina patients to receive that phone call. The risk of infection is extremely low, according to Allina spokesman David Kanihan, and the nurse practitioner no longer works for Allina. But Lightfoot wasn't entirely appeased.
"It's low risk, but it's not no risk," Lightfoot said, after researching the issue. "I feel like I'm still in the dark really. I was sort of expecting a letter sent overnight mail from the CEO apologizing."
Allina said the HIV and hepatitis tests — free of charge to those affected — are being done out of an abundance of caution. Risk of infection is less than 1 percent, Kanihan said.
"While the risk of infection is very low, we understand that this is upsetting and concerning to these patients and families," Allina said in a prepared statement. "We will learn from this incident and are taking action consistent with our commitment to patient safety."
The nurse practitioner never reused the needle but did reuse the syringes, sometimes multiple times, according to Kanihan.
NO REPORT TO STATE
"The breach in infection control practices is serious because of the ... the significant health risks that these pathogens carry for those infected," Minnesota Department of Health spokesman Doug Schultz said in an email.
It was the first time in recent memory that Health Department staff could recall syringes being reused in a licensed medical facility, Schultz said, but he didn't have state data on it because health care facilities are not required to inform the department of infection-control breaches.
"Nevertheless, we do know that such instances occur. Nationally, we know that in recent years, unsafe injection practices have affected more than 150,000 patients. From 2001 through 2011, there were at least 50 outbreaks of viral hepatitis or bacterial infections associated with unsafe injection practices in outpatient settings such as physician offices or ambulatory surgical centers. This is believed to be the tip of the iceberg," Schultz said in the email.
PROTOCOL NOT FOLLOWED
The practice is contrary to protocol, Allina states.
The nurse practitioner's behavior began in October and continued through February. Other Allina health care professionals noticed the problem and reported it, prompting an investigation.
Allina apologized and said it is committed to doing the right thing if any of the patients' tests reveal any issues.
Kanihan did not know why the terminated employee had not followed protocol.
The nurse practitioner, who had been with Allina for several years, could not immediately be reached for comment Monday.