Covenant Health yesterday mailed letters to 1,307 patients who may have been exposed to Hepatitis B and C through an infection control breach that occurred during individual insulin training sessions at the Grey Nuns and Misericordia Community Hospitals Diabetes Education Centres, between 2013 and early 2016.
The risk to the individuals being notified is considered very low. However, as a precaution, all affected patients are being advised to be tested for both the Hepatitis B and C viruses.
This risk is not ongoing, and only those individuals who receive notification letters from Covenant Health are considered exposed.
“The health and well-being of our patients is our top priority,” says Dr. Owen Heisler, Chief Medical Officer of Covenant Health. “We believe we have a responsibility to notify our patients of this risk, even though it is very low. Covenant Health is committed to ensuring best practice and safety for all patients and staff, which is why we are making sure this information is readily available to the public.”
The infection control breach was associated with the use of saline-filled demonstration pens and the pillows used for practice. Though the needle in the demonstration pens was changed with each use and needles were never shared between patients, the pen’s saline reservoir may not have been changed with every patient. Additionally, the practice pillows may have been used by multiple patients using their own pens.
This incorrect training practice was discontinued immediately upon being identified in February 2016. Covenant Health then proactively requested Alberta Health Services’ (AHS) Risk Assessment Panel (RAP) review the issue, and provide recommendation as to patient notification.
The RAP advised Covenant Health to notify patients with diabetes or gestational diabetes who received insulin pen training at:
- Grey Nuns Community Hospital Diabetes Education Centre between March 2013 and February 19, 2016; or
- Misericordia Community Hospital Diabetes Education Centre between May 2014 and February 19, 2016.
Letters have been sent to all patients the RAP recommended be notified.
The RAP also advised that children born to patients with gestational diabetes who received this training do not require testing.
New guidelines for saline-filled demonstration pens have been developed and implemented at all Diabetes Education Centres. Staff have also received upgraded orientation and education regarding saline-filled demonstration pen use.