WASHINGTON – More than 700 patients at the Buffalo VA Medical Center may have been exposed to HIV, hepatitis B or hepatitis C because of the inadvertent reuse of insulin pens that were intended to be used only once.
The possible reuse of the insulin delivery devices occurred between Oct. 19, 2010, and Nov. 1, 2012, the U.S. Department of Veterans Affairs said in a memo sent Friday to local members of Congress, which The Buffalo News obtained.
“There is a very small chance that some patients could have been exposed to the Hepatitis B virus, the Hepatitis C virus, or HIV, based on practices identified at the facility,” the memo said.
The VA told local lawmakers that 716 patients at the facility may have been exposed to the reused insulin pens, and that 570 of those patients are still living.
A routine pharmacy inspection revealed the problem last Nov. 1, when the insulin pens were discovered in supply carts without patient labels on them, thereby indicating that they may have been reused, the VA memo said.
The local veterans hospital “recently discovered that in some cases, insulin pens were not labeled for individual patients,” said Evangeline Conley, a spokeswoman for the hospital. “Although the pen needles were always changed, an insulin pen may have been used on more than one patient.
“Once this was identified, immediate action was taken to ensure the insulin pens were labeled and only used according to pharmaceutical guidelines. The hospital immediately changed its procedures to prevent insulin pens from being reused,” Conley added.
After seeing the VA’s memo on the matter, Rep. Chris Collins, R-Clarence, spoke with Dr. Robert A. Petzel, undersecretary for health at the Department of Veterans Affairs.
“His thought was that it’s a very, very low chance of passing infection,” Collins said. “But it’s not out of the realm of possibility, and that’s why they’re testing everyone.”
Nurses apparently changed the needles used with the insulin pens with every single use, but even with a fresh needle, contamination could have occurred if bodily fluid had flowed back into one of the insulin pens during a previous injection, Collins said.
VA officials believe the infection risk would have been far worse if the needles themselves were reused. “That would have been a grave concern,” Collins said. Given the possibility that infections may have occurred, the VA is reaching out to the patients who may have been given insulin with a used insulin pen.
The agency is setting up a nurse-staffed call center to handle calls from concerned veterans, as well as planning to send a letter to every veteran who may have been infected.
The Buffalo VA hospital began using the insulin pens to deliver insulin to diabetic patients on Oct. 19, 2010, and the misuse of the pens appears to have begun on that very same day, the VA said in a draft of that letter.
“At this point, we cannot tell whether your insulin was given using a properly labeled insulin pen,” Brian G. Stiller, medical center director, said in that draft, which was obtained by The Buffalo News. “Although your risk for infection is felt to be very low or nonexistent, we are offering blood tests to rule out any infections needing treatment. There will be no charge or co-pay for your visit.”
So far, the VA has not identified any patients who were infected at the Buffalo facility through the repeated use of insulin pens, the VA said in a handout it is sending to veterans who may have been infected. After the problem was discovered, local VA officials conducted a “root cause analysis,” and they now plan to develop an action plan based on that analysis.
In addition, the VA National Center for Patient Safety was notified about the problem in Buffalo, and is developing a patient safety alert to be shared with other VA medical facilities to make sure the error doesn’t recur anywhere else.
Collins said the VA “is being open and transparent” about the problem, but still, there are concerns. “It doesn’t diminish the fact that it did go on for two years here,” Collins said.
Meanwhile, Sen. Charles E. Schumer, D-N.Y., was aghast upon hearing of the reuse of the insulin delivery pens.
“What has happened can only be described as the grossest of irresponsible and dangerous behavior,” he said. “The VA must immediately deal with the health of those that were victimized, and promptly launch a top-to-bottom investigation to root out how this happened and tell us what is being done to prevent it from ever happening again, in Buffalo or elsewhere in the country.”