**DaVita Centers Mess Up Reuse Filters, Again!**

[Zach]

Another reason not to accept reuse at your center.

http://cbs4denver.com/news/Colorado.health.officials.2.1998965.html

Nov 6, 2010 10:45 am US/Mountain

State OKs Dialysis Centers' Correctional Plans

COLORADO SPRINGS, Colo. (AP) ― The Colorado health department has signed off on correctional plans for two dialysis centers that each treated a patient with an artificial kidney belonging to someone else.

Health officials investigated the Pikes Peak and Printers Place centers in Colorado Springs in May after learning two patients were treated with the wrong dialyzer.

The Gazette reports that one patient was treated with a dialyzer belonging to a patient infected with Hepatitis C, and another was treated with one used by a patient infected with methicillin-resistant staph, or MRSA (MUR-suh).

Denver-based DaVita owns both dialysis centers. Dr. Robert Provenzano of DaVita says three employees, not just two, will now check patients' dialyzers.

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Information from: The Gazette, http://www.gazette.com

[greg10]

Thank you Zach.  Initially Davita did not report the incidents to the Colorado health department, which is even more troubling.  Dr. Fox below said he has only seen one mix-up in 22 years, but those are only the ones that were reported.  These incidences could happen more often than is reported.

According to the Gazette:   http://www.gazette.com/articles/dialysis-102290-three-mix.html

Mix-ups with reusable dialyzers don’t occur often, though. An official with the Colorado health department said the Colorado Springs cases are the first she’s encountered in seven years at the agency, and Dr. Stephen Fox of Pikes Peak Nephrology Associates said he had seen only one in his 22 years of practice.

“So to have two incidents in a short span of time is very unusual and very troubling,” said Fox.

Lazarus said that getting the wrong dialyzer rarely puts the patient at risk. Sterilization of dialyzers after each use kills most pathogens, including MRSA, he said, so Preston Price is likely in the clear.

“In 99 percent of the cases, it doesn’t matter. It’s like wearing someone else’s underwear; it’s not pleasant, but it doesn’t hurt anyone,” said Lazarus. “There’s a big psychological issue: ‘My blood is going through this artificial kidney that someone else has used.’”

More troubling is the patient who was exposed to Hepatitis C, because neither that virus nor AIDS can be killed with current sterilization techniques, he said.

And there’s no guarantee that the cleaning and sterilization process will go according to plan. In 2007, a 71-year-old Muskegon, Mich., woman being treated at a DaVita center died after being hooked to a dialyzer that wasn’t properly rinsed after cleaning. The corrosive cleaning agent got into her bloodstream and killed her.