 |
| Credit: One and Only Campaign |
At least two Veterans Affairs (V.A.) medical centers in New York and North Carolina, and one general hospital in New York have recently detected potential exposures as a result of improper insulin pen re-use in former inpatients. Officials in the Buffalo V.A. Medical Center (N.Y.) uncovered several incidents over a two year period where multi-dose insulin pens intended for use by a single patient were reused on more than one patient. Although the needles were changed, the stored insulin could have been contaminated by a back flow of blood; changing the needle does not make it safe for multi-patient use. As a result of these unsafe injection practices at least 700 former inpatients were notified and tested.
The case in New York prompted an audit of practices in all
V.A. medical centers across the country.
During an audit at the W.G. Hefner V.A. Medical Center in Salisbury, N.C., auditors
uncovered insulin pen re-use identical to what was reported in NY. So far, at least 200 former inpatients have
been notified and tested following the potential exposures.
A similar case to those reported at the V.A.s occurred at Olean General Hospital in New York. Multiple instances of inadvertent reuse among inpatients from 2009-2013, resulting in notification of more than 2000 former inpatients. Following notification, at least 3 lawsuits have been filed by former patients alleging contracting hepatitis C as a result of the exposure and a potential class action suit against the hospital, its managing organization, and two pharmaceutical companies who manufactured pens used by the hospital.
All facilities have suspended use of insulin pens.
Insulin Pen Safety Recommendations
- Insulin pens are meant for use on a single person only, and should never be used for more than one person, even when the needle is changed.
- Insulin pens should be clearly labeled with the person’s name or other identifying information to ensure that the correct pen is used only on the correct individual.
- If use of a pen for more than 1 person is identified, consider this a reportable error; exposed patients should be promptly notified and offered appropriate follow-up, including bloodborne pathogen testing.
These recommendations apply to any setting where insulin
pens are used, including assisted living or residential care facilities,
skilled nursing facilities, clinics, health fairs, shelters, detention
facilities, senior centers, schools, and camps as well as licensed healthcare
facilities. Protection from infections, including bloodborne pathogens, is a
basic expectation anywhere healthcare is provided. Use of insulin pens for more
than one person, like other forms of syringe reuse, imposes unacceptable risks
and should be considered a 'never event'. Hospitals and other facilities should review
their policies and educate their staff regarding safe use of insulin pens and
similar devices.
References:
CBS News, January 15, 2013. N.Y. hospital patients
potentially exposed to HIV, hepatitis through reused insulin pens. (http://www.cbsnews.com/8301-204_162-57564040/n.y-hospital-patients-potentially-exposed-to-hiv-hepatitis-through-reused-insulin-pens/)
E Cook. Misuse of insulin pens at VA leads to testing. Salisbury
Post, March 8, 2013. Print
Center for Disease Control and Prevention (CDC) and the Safe
Injection Practices Coalition (SIPC)
