WASHINGTON – For more than two months, officials at the Buffalo VA Medical Center knew that a faulty nursing practice may have exposed diabetic patients to HIV, hepatitis B or hepatitis C – and for all that time, the hospital failed to tell the affected patients or the public.
That fact prompted an angry outcry Tuesday from three federal lawmakers who said they are worried the delay may have further harmed the health of any veteran who might have been exposed through the hospital’s improper reuse of insulin pens that were designed to be used only once.
Two of those lawmakers – Sen. Charles E. Schumer and Rep. Brian Higgins – asked the inspector general of the U.S. Department of Veterans Affairs to investigate the hospital’s error, which, the hospital said, could have exposed 716 patients to deadly viruses.
The hospital discovered the problem last Nov. 1 but did not make its error public until sending an advisory to local members of Congress on Friday.
That delay is “unacceptable,” Schumer said in a letter to George J. Opfer, the inspector general at the Department of Veterans Affairs.
“We are well aware that time is critical in all health care situations, and the sooner these veterans are tested and treated for any virus or condition they may have, the sooner they can be treated and monitored,” said Schumer, D-N.Y.
Higgins, D-Buffalo, echoed that concern in his separate letter to Opfer and said in an interview: “In a situation like this, where lives are at stake, you have an obligation to inform the public and the affected patients immediately. There’s no acceptable reason or explanation for delaying.”
Rep. Chris Collins, a Clarence Republican who was the first local lawmaker to voice concerns about the reused insulin pens, termed the delay “inexcusable.”
Asked for an explanation of the delay in disclosing the error, Evangeline Conley, a spokeswoman for the Buffalo VA Medical Center, said: “We wanted to make sure that we conducted a comprehensive review to identify all patients who may have been affected and develop an action plan to notify veterans and their families, so that we could address their concerns and provide all the information they needed.”
But that explanation didn’t pass muster with Higgins.
“That should have taken about three to five days,” he said.
Meanwhile, Collins said: “The hospital is being open and transparent about this today. But there’s two months of darkness before that that I have to question.”
The VA hospital’s long silence is just one of the issues that Schumer and Higgins want the inspector general to investigate.
“We must use all available resources to ensure that we find out what happened in this case and prevent any future incidents,” Schumer wrote to Opfer. “Our veterans and heroes deserve this and more.”
Higgins agreed, saying in his letter to the inspector general: “We must evaluate the root causes of this unthinkable error, identify who is responsible for this systematic failure, better understand if it is an isolated incident or representative of widespread problems and ensure it never happens again.”
Schumer and Higgins asked the inspector general to determine how the reuse of the insulin pens happened and why the problem went undetected for two years as well as why it took the hospital more than two months to disclose the problem.
The VA has said the risk of infection stemming from the used insulin pens is extremely small, and far smaller than it would have been if needles had been reused.
Still, Schumer and Higgins said that a full investigation is in order and that the VA needs to implement clear policies that will prevent such grave errors from recurring.
If such an investigation is performed, it could be handled by the inspector general’s Office of Healthcare Inspections, which was created to monitor veterans’ health care.
Beyond the investigation, Collins suggested that the Buffalo VA Medical Center compare its practices with those of other local health care providers to make sure it is offering veterans the best possible care. He said the VA’s reuse of the insulin pens was most likely an anomaly.
“I’m fairly confident that you would not see anything like this at Kaleida, Catholic Health System or ECMC,” Collins said, adding that the kind of best-practices review he is suggesting “happens all the time in the private sector” and ought to happen in government as well.