Buffalo, NY – Authorities report that more than 700 patients admitted to The Veterans Affairs Western New York Healthcare System over a two-year period, may have been exposed to blood-borne infectious diseases. Blood-borne diseases included Human immunodeficiency virus (HIV) and hepatitis B and C.
In this situation, multi-dose injectable insulin pens indented for single person use, were instead used to treat multiple patients. The hospital’s storage of insulin could have also been contaminated through needle flow back. The reuse of insulin pens is akin to the reuse of other syringes, potentially spreading pernicious diseases from one unsuspecting patient to another.
The Buffalo hospital began using insulin pens in October 2010. An inspection in November 2012 led to the discovery that the pens had likely been used on more than one patient.
CBS News reports, federal health agencies have been warning against sharing insulin pens for several years. The Food and Drug Administration (FDA) issued an alert in March 2009 after learning that more than 2,000 patients may have been exposed at a Texas hospital between 2007 and 2009. A clinical alert from the Centers for Disease Control and Prevention (CDC) last year came amid continued reports of the practice.
Dr. Melissa Schaefer of the CDC said Monday:
“This just shouldn’t happen, but it does. And I think the incidents we hear about are likely under-reported.”
More than 150,000 patients have been impacted by unsafe injection practices since 2001. The CDC sponsors a One and Only Campaign, used as an educational tool. The One and Only Campaign aims to eradicate avoidable outbreaks from unsafe medical injections by raising awareness among patients and healthcare providers about proper practices. The CDC urges that each medical establishment undergo proper Blood-borne Pathogens Training, which not only protects the patient but the administrators from possible exposure from mishandling samples and needles.
There have been cases where clinicians and technicians have intentionally contaminated needles thorough drug addiction. Last year, David Kwiatkowski, a lab technician absconded with syringes containing the powerful painkiller fentanyl. He acquired them from the cardiac catheterization lab at New Hampshire’s Exeter Hospital. In hopes of covering his tracks, David replaced the used fentanyl syringes with saline. However, they were tainted with his blood. Over 40 people have since been diagnosed with the same strain of hepatitis C that Kwiatkowski carries.
During the summer of 2012, Colorado oral surgeon, Dr. Stephen Stein, was accused of repeatedly reusing needles in his practice over a 12 year period. Stein was accused of saving unused drugs in syringes and then combining those drugs into another syringe, used later on another patient. The Colorado Department of Public Health looked into the matter and initially found five patients who tested positive for a blood disease. It is possible up to 8,000 people could have been exposed while under his care.
Representatives of the Department of Veterans Affairs indicate they’ll be contacted previous patients in the reused pen case. The VA will establish a nurse-staffed call center to field notifications and respond to questions. Blood tests and follow up care will be arranged. Employees will be given educational material on the proper use of insulin pens, in order to eliminate the threat of spreading disease.
The VA’s National Center for Patient Safety has also been asked to prepare a safety alert for all VA facilities. The notices are designed to reinforce best practices for patient care.