Don’t Call it an Accident: 700 Veterans Possibly Exposed to HIV
More than 700 patients in the Buffalo Veteran’s Administration Hospital may have been exposed to HIV, various forms of Hepatitis, and other blood-borne diseases. A number of news outlets such as ABC, and the Huffington Post have used the word “accidental” in their reports of this recent development. When considering the means by which this exposure has occurred, however, it is clear that a more appropriate word would be “negligent.”
A memo released by the U.S. Department of Veteran Affairs reported that between October 2010 and November 2012, single patient use insulin cartridges were used on multiple patients. Diseases could be transmitted if bodily fluids flowed into the cartridge during use.
Although according to Rep. Collins of Buffalo, the chance of disease transmission in this instance at Buffalo V.A. is “very, very low,” the Institute for Safe Medication Practices wrote in 2008, “at least two studies have shown that biological contamination of insulin occurred in up to half of all insulin pen cartridges” that had been used on multiple patients in hospitals.
This is not the first time that has happened in an army hospital. In 2009, Bloomberg.com reported that a hospital in Texas and another in Louisiana made the same mistakes in administering insulin. At that time, FDA reported that “current instructions for use for all insulin pens already state that the pens are not to be shared among patients.” If in 2009, all insulin pens were labeled for individual patient use, why did the same errors occur up to 2012?
It is not clear why an increasing number of hospitals are choosing to use reusable insulin pens. A pen for each patient requiring insulin injections must be stored in proper conditions labeled with the patient’s name. According to Buffalo Business First, routine inspection found cartridges without any patient name label. Reusable insulin pens have a place in a private home, but not in a hospital where improper training on safety standards (or, more concisely: negligence) can spread disease.