January 14, 2013
The U.S. Department of Veterans Affairs (VA) has informed local lawmakers and members of Congress that 716 patients at the Buffalo VA Medical Center may have been exposed to HIV, hepatitis B, or hepatitis C because of the inadvertent reuse of insulin pens that were intended for one-time use. The VA says that 570 of those patients are still alive. The possible reuse of the insulin pens happened between October 19, 2010, and November 1, 2012, according to the VA memo sent on January 11. The memo states that health officials discovered the problem during a routine pharmacy inspection last November 1 when they found insulin pens without patient labels attached to them in supply carts, thus revealing the possible reuse of the insulin pens. Hospital spokeswoman Evangeline Conley explained that once officials detected the problem, the hospital immediately took action to ensure that the insulin pens were used according to pharmaceutical guidelines, that the insulin pens were labeled, and that the hospital changed its procedure to prevent the reuse of insulin pens.
The VA plans to send a letter to every veteran who may have been infected, and is also establishing a nurse-staffed call center to handle calls from concerned veterans. Rep. Chris Collins (R-N.Y.), after speaking with VA Undersecretary for Health Dr. Robert A. Petzel, stated that "[Petzel's] thought was that it's a very, very low chance of passing infection, but it's not out of the realm of possibility, and that's why they're testing everyone." So far, the VA has not found any patients who were infected at the Buffalo VA Medical Center; the VA is carrying out an analysis of the cause of the problem and developing an action plan based upon the analysis. The VA National Center for Patient Safety is developing a patient safety alert for other VA medical facilities to ensure that this error does not occur anywhere else. Collins notes that the VA is being "open and transparent" about the problem; however, he states, "It doesn't diminish the fact that it did go on for two years here."
Sen. Charles E. Schumer (D-N.Y.), stunned after hearing of the reuse of the insulin delivery pens, declared, "What has happened can only be described as the grossest of irresponsible and dangerous behavior." He urges the VA to deal immediately with the health of those who were victimized and launch a thorough investigation to let everyone know what will be done to prevent this problem from happening in Buffalo or anywhere else in the country again.