New York’s senior Senator is demanding that veterans and their family members who sought treatment at the Buffalo Veterans Administration hospital be immediately tested for HIV and hepatitis. At least 716 patients may have been exposed to contaminated insulin syringes because of errors in the labeling and storage of insulin injection devices. Schumer calls the screw-up at the VA ”negligent” and says the hospital has put both patients and their caregivers at risk of serious or even fatal diseases.
The insulin syringe story will shock anyone who has ever worked in health care, because of the VA’s failure to follow the most elementary principles of infection control and good medical practice. For two years, 2010 to 2012, the hospital used disposable, multi-use insulin pens to administer the drug. These pens are intended for one patient and one patient only. Last November, a routine inspection found a medications cart with a bunch of used insulin pens, but none had a patient name or chart number. Nurses changed the needles for each shot, but allowed several patients to use the same insulin vial in the pen. Federal health officials say sharing multi-use drug containers risks transmitting a disease from one person to another via the drug.
The VA is downplaying the whole thing, telling patients this is no big deal. The hospital medical director told the 716 potentially infected people that “we cannot tell whether your insulin was given using a properly labeled insulin pen,” but “your risk of infection is felt to be low or nonexistent.” He didn’t explain how he arrived at that conclusion. The VA Inspector General’s Office says it is on the case and will do its best to determine how this situation managed to go undetected for two years and, once it was discovered, why it took several months to notify patients and families about the possible exposure. Asked how this could possibly happen, the Buffalo VA’s chief of medicine describes this failure of basic infection control procedures as a “variation of nursing practices.” He won’t explain how it all happened but promised to “fix our practice.”
Source: WKBW-TV, “Schumer calls on feds to ensure family and caregivers of Buffalo VA victims are also tested,” Jan. 23, 2013