BUFFALO, N.Y. -- Congressman Brian Higgins and Senator Charles Schumer Tuesday called for an independent investigation into the misuse of insulin pens at Buffalo's VA Hospital.
According to a memo obtained by 2 On Your Side, hundreds of local veterans may have been exposed to HIV or Hepatitis B or C at the Buffalo VA Medical Center, due to a mistake made at the facility.
The memo says the agency found some insulin pens that should have been used once, but that may have been used for multiple patients.
Those with questions about this matter should call the VA at (716) 862-8828.
"We must evaluate the root causes of this unthinkable error, identify who is responsible for the systematic failure, better understand if it is an isolated incident or representative of widespread problems and ensure it never happens again," said Higgins.
According to the Department of Veterans Affairs, the agency is informing about 550 people in Western New York who may've been infected. The patients are being asked to have a blood test to make sure they're okay. The VA says that there's a small chance these patients could've been exposed.
The VA's independent Inspector General must leave no stone unturned in its investigation as to how 716 patients in Buffalo were victims of the negligent and improper use of insulin pens," said Senator Schumer. "These patients and their families need answers now. As the VA conducts a thorough and independent investigation, it should also implement clear policies that will prevent future catastrophes like this one from ever happening again down the road."
The VA is contacting everyone who was injected there with insulin pens at the facility between Oct. 19, 2010 and Nov. 1, 2012.
The VA has informed Congress of the problem.
"Unfortunately, from 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," said U.S. Rep. Chris Collins (R - 27th District).
The VA says that needles were discarded each time the pens were used. The VA says it learned of the possible infection in early November when the audit was done on the VA's pharmacies.
That's when they say they found many insulin pens without a patient's name on them.
According to the Centers for Disease Control and Prevention, the pens should be labeled, with the person's name and any other relevant information. There should be no sharing of the pens, even when the needles are discarded. If this doesn't happen, patients who are injected with reused pens could be infected.
"Once this was identified, immediate action was taken to ensure the insulin pens were labeled and only used according to pharmaceutical guidelines. VA is committed to ensuring Veterans receive the care they earned and deserve, and to assuring high quality, patient-centered care as our top priority," said Evangeline Conley, public affairs officer of the VA Western NY Healthcare System.
Collins says that 716 people were injected with the pens. Of this number about 550 are alive.
"It would be highly unlikely that activity like that would cause the death of an individual, it could cause them to contract one of those three viruses," said Collins.
Cross contamination can occur if bodily fluid backed up in the insulin pens and were reused.
Still, the patients who are at risk are being contacted to get a blood test to make sure they're okay.
The VA says that needles were discarded each time the pens were used. The agency adds that other patients properly received insulin through pens that were labeled.
Collins is calling for a review of the medical center's policies.
WEB EXTRA: FULL MEMO
Department of Veterans Affairs (VA)
Congressional Information Sheet
Veterans Affairs Western New York Healthcare System
Single Use Insulin Pens
The Department of Veterans Affairs (VA) leadership takes seriously its responsibility to ensure that the highest quality of care is provided to the Veterans we serve. As part of its commitment to transparency, VA strives to keep Veterans, their families and the public informed of any quality of care issues that may arise.
Officials at the VA Western New York Healthcare System (VAWNYHS) in Buffalo, NY are notifying individual Veterans that may have been potentially exposed to the Hepatitis B Virus, the Hepatitis C Virus, or the Human Immunodeficiency Virus (HIV).
On November 1, 2012, officials at the VAWNYHS 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. The insulin pens are intended for individual patient use and have been in use at VAWNYHS since October 19, 2010. 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.
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. Other patients received insulin through properly labeled insulin pens and had no risk of exposure to blood-borne illnesses. Since the facility has not determined when the variation in nursing practice occurred or which Veterans may have been potentially impacted by this practice, VAWNYHS 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.
As part of the full disclosure process, VAWNYHS will be completing a thorough review and notification to all Veterans potentially impacted. This will include the following actions:
• Identifying Veterans who received insulin from an insulin pen during the period in question and preparing the final list for notification process.
• Conducting clinical review of all cases.
• Providing education packets on appropriate use of insulin pens to all applicable staff members.
• A nurse staffed Communication Call Center is being established to conduct initial Veteran notification and manage clinical care follow-up to include:
- making initial contact regarding the topic;
- answering questions and providing pertinent information to the Veteran;
- assisting in arranging the necessary blood tests or medical follow up;
- document patient encounters;
- Mailing of notification letters to Veterans in follow-up to nursing team contact; and
- Managing and tracking Veteran contacts, blood test results and any follow-up testing or treatment
• Updates will be provided to VHA leadership on a regular basis.