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SALISBURY, NC (WBTV) -
The Salisbury VA Medical Center has recently discovered that in some cases, insulin pens prescribed for use on one patient were used on more than one patient.
Although the insulin pen needles were always changed, it was discovered that the pens were used on more than one patient, according to a spokesperosn at the W. G. "Bill" Hefner Veterans Administration Medical Center.
Even though the risk is very low, according to the VA, the Salisbury center took immediate action to ensure the insulin pens were removed from all inpatient units and to offer testing and treatment to affected patients.
The Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) state that by only changing the needle, patients are put at risk for blood-borne pathogens due to possible back flow into the device.
The Hefner VA used insulin pens from September 1, 2010, until January 10 of this year. At that time all of the pens were collected from all inpatient care settings and returned to the pharmacy.
Carol Waters with the VA's Public Affairs Office told WBTV that the medical center has taken several steps to identify and notify those patients who may have been affected in the last few days. Telephone calls are being made to potentially affected veterans, certified letters have been sent, a call center has been established, and all policies and procedures have been reviewed with the medical center staff.
Waters said that 205 patients have been identified as potentially affected. All patients were treated in two areas: the Community Living Center, and the Medical unit.
An insulin pen is a small device which contains a reservoir of insulin that can be used for multiple injections. Sterile needles are supposed to be changed with each patient. When the multi dose pens are used, bodily fluids can potentially back flow into the insulin reservoir, creating risk for blood-borne diseases, if the pen is used by more than one patient.
Incidents involving multi dose insulin pens across the country have led to multiple lawsuits against medical centers and pharmaceutical companies. On January 24, officials from Olean General Hospital in western New York near Buffalo sent letters to 1,915 former patients warning them they may have potentially been exposed to HIV and hepatitis strains through the possible reuse of the pens between November 2009 and January 16 of this year. Hospital officials urged recipients to get blood tests for the diseases and indefinitely suspended use of the devices.
In Wisconsin three years ago, more than 2000 patients were potentially exposed to blood borne diseases due to inappropriate sharing of insulin demonstration pens used during patient training.
According to Michael Gaunt, PharmD, who writes in Pharmacy Times, two reports submitted to the ISMP National Medication Errors Reporting Program describe nurses knowingly using the same insulin pen for multiple patients. Both nurses thought the practice was acceptable because they changed the needle between patients. In one case, it was later determined that the original patient had HIV.
The CDC recently issued a clinical reminder stating that the agency has increasingly become aware of reports of improper use of insulin pens, which places individuals at risk of infection.