HONOLULU (HawaiiNewsNow) - At least five nurses at the state's Leeward clinic in Waipahu have been temporarily removed from clinical duties after administering flu shots to patients seeking tubercolosis tests.
Officials with the state Department of Health say they're aware of four patients who went to the Waipahu Civic Center office on Monday for a TB test and got a flu shot instead.
But 89 people sought TB tests at the clinic that day, so more people could be impacted. Clinic staff has notified all patients about the mistake, which could have costly consequences.
"We have followed up with every individual by phone as soon as we knew that this happened," said Danette Wong Tomiyasu, deputy director of the state Health Department's Health Resources Administration. "We notified every one of the individuals in the clinic that this happened and what some of the reactions might be."
Angela Midro, 30, has taken TB tests before but says the experience with her nurse at the Leeward clinic on Monday was unusual.
"She was filling out the paperwork and another nurse came and handed her the syringe and just put it on the counter. She just took my hand and she was just rubbing this area -- she didn't swab it like they normally do -- and then she just poked it," Midro said.
Hours later, Midro got a call at home.
"They had somehow mixed up the vials throughout the day and the nurse had injected me with the influenza instead of the TB under my skin," she said.
The next day, Midro got an apology letter in the mail offering to cover any medical expenses caused by the mix-up and inviting her to return for the correct test.
"I know they contacted me, but does everybody know that was in that clinic and have they gotten checked out, are they OK?" Midro said. "I know that it can be serious to the point where if someone was allergic to the shot they could have trouble breathing. It could be fatal. It's not just a itch or a rash. It could be extreme."
Midro did have to go to the doctor when her injection site swelled and began to welt up.
State Health Department officials say there are a "handful" of others who are also being monitored for side effects.
"This is such an unusual type of incident, the nurses are taking it extremely hard," Tomiyasu said. "They feel very remorseful. Nurses are trained to help people, not hurt people and so when they found out this happened, they were just devastated."
The state says vials containing the influenza vaccine and tubersol, which is used for the TB test, are stored in the same refrigerator. Nurses are supposed to cross-check the vial with both the patients and their charts before administering any shots.
TB tests are commonly administered in Hawaii. Students and those starting jobs in schools, health care, the food industry and other sectors must be tested. The state has TB testing locations like the Leeward clinic statewide where TB tests are administered for free to those required to get them.
Officials say they're now reviewing procedures to identify how the error occurred.
"We don't know where it is, and that's why we're doing an investigation," Tomiyasu said. "We don't know what process or what steps may have been missed in this case, and then we'll work to figure that out."