WASHINGTON – The inspector general at the U.S. Department of Veterans Affairs has initiated a review of practices at the Buffalo VA Medical Center that could have exposed more than 700 patients to HIV, hepatitis B or hepatitis C.
The inspector general, George Opfer, confirmed the review in letters to Rep. Brian Higgins, D-Buffalo, and Sen. Charles E. Schumer, D-N.Y., the lawmakers said Tuesday.
Both lawmakers said they are happy the review is under way.
“It is critical that we get to the bottom of this so we can work urgently to correct the flaws in the system that led to this situation and make changes to ensure nothing like this ever happens again,” Higgins said. “We appreciate the inspector general’s serious and swift attention to this matter and await the results of his review.”
Catherine Gromek, a spokeswoman for Opfer, said the Inspector General’s Office would not comment on how long the review will take or on anything else about it until it is complete.
Schumer, though, called for a “swift and thorough” review.
“This astounding failure to follow proper protocols at the VA hospital requires answers in order to help address any and all health concerns for patients, and to avoid … this from ever happening again,” Schumer said.
The lawmakers asked for the inspector general to get involved after the hospital acknowledged that it may have been reusing insulin pens on different patients even though the insulin delivery devices are designed to be used on only one patient.
Because the hospital was not labeling the insulin pens for use by individual patients, 716 people could have been infected between Oct. 19, 2010, and Nov. 1 of last year, the hospital said.
The faulty practice started despite a 2009 Food and Drug Administration warning against reusing insulin pens, and it continued despite a similar January 2012 alert from the Centers for Disease Control and Prevention – warnings that hospital officials said they had not seen.
Higgins, Schumer and Rep. Chris Collins, R-Clarence, all have pressed the VA for details about what happened. While the VA discontinued the use of the insulin pens after discovering the error and invited the potentially affected patients in for tests, the lawmakers have said there are still serious questions outstanding.
Higgins spelled out those questions in a letter to Eric Shinseki, the secretary of veterans affairs.
“Please explain why it took two years to discover this error and what new checks and balances are being implemented to prevent future medical errors hospital-wide,” Higgins said in that letter. “Also detail why affected patients weren’t notified immediately.”
In addition to the inspector general’s review, the House Committee on Veterans Affairs is planning to hold a hearing on the problem at the Buffalo VA hospital at Collins’ request.
“It is my hope that this review, along with the upcoming House hearing on this matter that I have requested, will shine a spotlight on why this dangerous situation happened, how it went undetected for over two years, and what the Buffalo VA is doing to make sure it is following ‘best practices’ in the delivery of health care of our veterans,” Collins said.