No one could blame any veteran or, indeed, any American for being outraged at the recent revelation that more than 700 patients at the Buffalo VA Medical Center may have been exposed to HIV, hepatitis B or hepatitis C because of an unthinkable lapse in proper procedures.
The horrifying incident calls for an immediate top-to-bottom review of all procedures, not just the one in question.
The issue revolves around the inadvertent reuse of insulin pens over a two-year period, between Oct. 19, 2010, and last Nov. 1. Misuse of the pens appears to have begun on the very day they were delivered.
Veterans Affairs officials informed members of Congress that 716 patients at the facility may have been exposed through the reuse of insulin pens that were supposed to be used only once. Of those, 570 patients are still alive.
While the pen needles were not reused and VA officials are careful to explain that the likelihood of infection is very low, there’s always a chance that someone could have been infected. And even without the spread of infection, just the mental anguish at having to rush back to the center for testing is harm enough.
Were it not for a routine pharmacy inspection last Nov. 1, who knows how long the problem would have lasted? That’s when the insulin pens were discovered in supply carts without patient labels on them, indicating that they may have been reused, according to a VA memo obtained by The News.
Rep. Chris Collins, whose business background is widely known, made suggestions the VA should consider implementing, starting with a full “best practices” review of all its medical procedures to ensure there’s not another problem lurking at the hospital.
The “best practices” model involves comparing a company’s services or products with the best practices employed by other businesses. For years Collins has suggested that government adopt such tried-and-true business models.
Care at the Buffalo VA Medical Center has greatly improved over the last several decades, according to Patrick W. Welch, Erie County Veterans Affairs director from 2008 to 2010. Welch, who has diabetes but does not get insulin shots, made a strong case that the VA hospital should not be judged on one incident. We hope he’s right that it’s an isolated incident.
But the disregard of protocols for the insulin pens raises red flags about every procedure at the hospital. The only way to regain the confidence of veterans and their families is to conduct a complete review of hospital procedures. The investigation needs to be launched immediately.