WASHINGTON – Twenty veterans treated at the Buffalo Veterans Affairs Medical Center have tested positive for hepatitis in the wake of revelations that nurses improperly reused insulin pens on multiple patients, but all but two have cleared the virus, the hospital said Thursday.
Fourteen of the patients tested positive for hepatitis B, but those patients have cleared the infection and no longer can pass along the virus, said Evangeline E. Conley, hospital spokeswoman.
Meanwhile, six others tested positive for hepatitis C. Four of those patients have cleared the virus, while two show signs of chronic disease, Conley said.
“It’s certainly possible that the infection was caused by the use of these insulin pens across multiple patients, but we’ll never know for sure,” said Rep. Chris Collins, R-Clarence, who was briefed on the matter Thursday.
Conley agreed. “It should be emphasized that those positives did not necessarily get infected by their exposure,” she said. “We may just be detecting an infection that was acquired years ago unrelated to insulin pens.”
None of the patients tested to date showed evidence of exposure to HIV, the VA said.
The statistics released by the VA are the first that identify the number of hepatitis infections following the hospital’s admission, in January, that 716 of its patients could have been exposed to hepatitis or HIV because of the misuse of insulin pens on diabetic patients between Oct. 19, 2010, and Nov. 1, 2012.
Those insulin-delivery devices are designed to be used on one person each, but the hospital said some of the pens may have been used on multiple patients.
Of the 716 patients who may have been exposed to infection, 174 died before the hospital became aware of the problem involving the reuse of the insulin-delivery devices.
Some 85 percent of the living veterans who may have been exposed to infection have been tested, Conley said. The rest have tests scheduled soon, have been tested but have not yet received the results or have not responded to the VA’s attempts to contact them.
The VA’s release of the statistics on the reuse of the insulin pens came the same day that the Inspector General of the Department of Veterans Affairs released a report that offered more details of the incident, along with some scathing criticism of how it happened.
Investigators interviewed 37 nurses at the hospital, and five acknowledged that they had used the insulin pens on multiple patients, the report said. All the nurses worked in the same unit.
In addition, several other nurses throughout the hospital told investigators they frequently found unlabeled insulin pens on medication carts – meaning those pens also could have ended up being used on multiple patients.
Once the insulin pens were introduced at the hospital, officials there “failed to fully consider and/or mitigate the risks associated with using insulin pens,” the report said. “Furthermore, once the decision was made to use the pens, former facility leaders and pharmacy and nursing officials failed to ensure proper planning and coordination, adequate and timely training, and clear and ongoing guidance on the difference between insulin pens and multi-dose vials that have traditionally been used on inpatient units.”
Once the problem was discovered, though, the Buffalo hospital acted promptly to correct it and test those that might have been affected, the Inspector General’s report said.
The Inspector General also recommended that the Buffalo hospital improve its training of nurses when new products are implemented and that it begin a process to make sure that hospital leadership evaluates the risks and benefits before introducing new medical products into the hospital.
Collins said he was amazed that such evaluations were not already being done.
“It’s mind-boggling to me that anyone would introduce new products into a hospital without a process to evaluate the risks and the benefits,” he said.