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Posted on 01 May 2021
Incident response/review

No former quarantine residents exposed to potential cross-contamination have been identified as having contracted a blood borne virus as a result of having their blood glucose level tested.

Safer Care Victoria has published its review into how the wrong blood glucose testing devices were placed in the COVID-19 quarantine accommodation program, potentially exposing about 1700 people to blood borne viruses such as hepatitis B and C, and HIV.

Of those successfully contacted, many were found to have used their own device and were not at risk, or did not have the test. To date, 275 people have been referred for follow up testing, with no positive results related to this incident.

However, not all residents identified in the review of health records were able to be contacted, despite multiple attempts.

If residents believe or are unsure if they had this test, they can call the dedicated patient line on 1800 356 061 (during business hours). Interpreters are available on request.

The clinical risk of infection is low. However, access to confidential testing will be arranged.

  • There is no risk to people who did not have a blood glucose level test.
  • There is no risk to those who used their own personal device to test their blood glucose level. 
  • There is no ongoing risk to people currently in COVID-19 accommodation, as the devices were removed in August 2020.
  • There is no risk that this spread coronavirus (COVID-19), as it is not transmitted by blood.

Download the summary report

Personal use blood glucose level testing devices were used across multiple people between the start of hotel quarantine on 29 March to 20 August 2020. Read more about the review 

The review found that the quarantine accommodation program was set up so quickly that important clinical governance was not established. That is, there was no guidance, training or oversight to help team leaders or registered nurses understand these devices were not appropriate for use on multiple people.

All 13 recommendations from the review have been accepted and have been implemented or are in progress, including improvements to:

  • Governance – including how to respond to health emergencies outside the hospital setting
  • Logistics and supply – ensuring fit for purpose medical equipment is purchased and used in quarantine accommodation
  • Nursing leadership – implementing a defined nurse leadership role at each quarantine accommodation site
  • Formal recruitment strategy – ensuring public sector staff are equipped to take on leadership roles in quarantine accommodation
  • Clinical practice guidelines, training and education – introducing formal orientation, processes and guidelines for registered nurses working in unfamiliar environments.