Do you know how close you are to disaster?

 

An interesting experience today showed me, once again, just how close we teeter to the edge of disaster in healthcare.

A few months ago medical device notice came across my desk from ERCI telling of problems with the LifeScan glucometer and cleaning with certain hospital products – specifically ones with hydrogen peroxide (H2O2) as an ingredient. So I sent it around, made sure everyone knew not to clean the monitors with the specific products that could alter the readings into false high readings. All was good – we were not using the specific wipes to clean the little hand-held monitors and we went on our business of performing blood glucose measures every 4 hours and making treatment decisions based on the readings.

So today, I hear about a ICU that discovered a reading of high that was, upon confirming with the lab, really normal. In doing some testing with placing their glucometers on surfaces recently cleaned with products containing hydrogen peroxide they discovered that just being in the vicinity of environmental areas that have been cleaned with H2O2 products can alter the glucose read upwardly. Holy crap on a stick.

This started a kuffufle of activity in trying to determine what we could do about this as all the monitors used in the area are the LifeScan monitors and while other company monitors don’t do this, it will take a few days to possibly weeks to make a change over. In the meantime there is a very real possibility of patients being treated erroneously based on a glucometer reading – or not being treated based on a glucometer reading. Chaos was knocking loudly on the door.

In trying to figure out our next steps I started digging – ECRI and FDA yielded nothing about this looming disaster. Google the one true God was there for me though. I discovered technical Bulletins released in April and June that clearly indicted this problem when the monitors were used in an environment that had been cleaned by these products. How was this information not passed along to a wide variety of care providers and locations? I had to dig to find this out and only after I had heard something about it first. How many patients have received or not received treatment based on wrong clinical measurements. Worse, how many have died?

I can feel the panic clawing at my guts when I look to try to figure out how we can suddenly accommodate hundreds of glucose measurements that need now to be performed in a different way. There is not the manpower to do it. The ensuing confusion and chaos will ultimately mean someone somewhere will have their blood glucose measurement done wrong and a wrong reading will be used to assign treatment and things will go badly.

Once you know about a problem you have to act. To know about it and wait is to put patients in danger and to be culpable in any harm.

Discussions and potential plans ensued while I continued on the track of cleaning solutions rather than changing glucometers and method of obtaining glucose results. Could we change the product?

Delight and relief to discover our site has not been using H2O2 products! We are free and clear, however, not so other places. In searching out this mystery I discover that the H2O2 products can take varying amounts of time to clear from affecting results (48 hours to 6 days!)

And so I reflect, as we are told we should do in these times, on how very closely we stand to the edge of danger. How easily a previously unknown chemical reaction can alter your treatment selection, and once implemented, harm a patient. How the hell do you deal with this kind of knowledge of the precariousness of health care? What’s more, how can we be assured of current up-to-date information on such discoveries that impact on our patient care? In doing some further digging I find that both providers and researchers at Calgary and Montreal discovered information about the artifical high glucose reading when the glucometer had been cleaned with Virox in 2005. 2005! Six years later we finally hear of it and then shortly afterwards the danger of using the H2O2 cleaning solutions in the environment where the monitors will be used.

Is it just me who sees a problem here?

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