11:44 AM, Jan 12, 2013
BUFFALO, N.Y. -- According to a memo obtained by 2 On Your Side, hundreds of local veterans may have been exposed to HIV or Hepatitis at the Buffalo VA hospital due to a mistake made at the facility.
The memo says VA workers found some insulin pens that should have been used once once, but that may have been used on more than one patient.
The memo says, "There is a very small chance that some patients could have been exposed to the Hepatitis B Virus, the Hepatitis C Virus, or HIV..."
The VA is contacting everyone who was in contact with insulin pens at the facility between October 19, 2010 and November 1, 2012.
A source tells 2 On Your Side up to 716 patients could have been impacted. Of those, 570 are still alive.
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.