More than 700 veterans may have been exposed to HIV, hepatitis B and hepatitis C due to improper use of insulin pens at a New York hospital. According to CNN, personnel at a Veterans’ Administration hospital in Buffalo, New York used the single-use injection pens on multiple patients, exposing them to the same risk of blood borne diseases as IV drug users who share needles.
A memo sent from the Department of Veterans’ Affairs to the Congress said, in part, “On November 1, 2012, officials at the (Veterans Affairs Western New York Healthcare System) reported that while conducting pharmacy inspection rounds on the inpatient units, they discovered that insulin pens intended for individual patient use were found in the supply drawer of the medication carts without a patient label on them. Although the disposable needles were changed each time it was used, the insulin pens intended for individual patient use may have been used on more than one patient.”
The office of Rep. Brian Higgins (D-NY) supplied the memo to CNN. The document went on to say that risks to veterans who were patients in the hospital was very low.
“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,” it reads. “(The health system) determined that all veterans who were prescribed the insulin pen during an inpatient stay from October 19, 2010, to November 1, 2012, should be notified.”
During that period, 712 patients were given doses of insulin from the disposable pens, which are injection devices intended to allow one person to perform multiple self-injections. Because blood can flush back up the needle into the cartridge during injection, pathogens left behind by one patient could potentially be passed on when the device is used on a second patient, even if the needle has been changed.
Jim Blue, regional director of the VA’s Office of Public and Intergovernmental Affairs, said to CNN, “Veterans and their families will have an opportunity to speak with a nurse who will answer questions they may have and assist with managing followup care.”
Higgins’ office took the VA to task in a statement for dragging its feet when it came to notifying the affected patients.
“Beyond the fact that the error occurred at all, most concerning was the length of time it took the Buffalo VA to catch the error — over two years, as well as the three-month delay in informing patients who may have been exposed,” it said.
Rep. Chris Collins (R-NY) blamed improper training of VA hospital personnel.
“Unfortunately, since the day that new technology was introduced at the VA, they did not have a protocol in place that let the nurses know they were not supposed to use the cartridge on more than one patient,” he said, calling the situation “unacceptable.”
Higgins has also requested an action plan from the VA that will ensure that such errors do not take place in the future.
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