Buffalo VA Center Exposes 700+ Veterans to HIV, Hepatitis
If you received insulin injections at the VA hospital in Buffalo, New York at any time between October 19th, 2010, and last November, get in touch with the clinic, pronto.
Hospital officials have disclosed that as many as 700 veterans may have been exposed to HIV – the virus that causes AIDS – as well as hepatitis A and B from the reuse of insulin pens.
The clinic claims that it was only the pens that were reused in this case, and not the needles themselves. But that is potentially enough to taint any insulin delivered with those pens, which were not designed for reuse.
The problem came to light when inspectors visited the hospital and found a drawer full of insulin pens that were not labeled for individual patients. Some pens are reusable, but in no case should unsterilized pens be used on more than one patient. The fact that unlabeled pens were retained and not discarded indicated that some staffers were unaware that these pens were not for use on multiple patients.
VA spokespersons indicated that as many as 716 veterans may have been exposed in this way.
The VA is setting up a hotline to deal with veteran inquiries.
Meanwhile, Senator Charles Schumer (D-NY) and Representative Brian Higgins are both calling for a top-to-bottom review of medical practices at New York VA hospitals and clinics.
They are also calling for answers about why it is that the problem went undetected for two years, and why, once the problem was discovered, it took over two months for VA officials to notify veterans or Congressional representatives.
“We must evaluate the root causes of this unthinkable error, identify who is responsible for this systematic failure, better understand if it is an isolated incident or representative of widespread problems and ensure it never happens again,” said Rep. Wiggins in a statement.
The VA is providing free blood tests to those affected to rule out any infections.
This incident is not the first in which VA medical centers have accidentally exposed patients to blood-borne pathogens through incompetence. Thousands of veterans were exposed to HIV and hepatitis when staff at VA hospitals and clinics in Miami, Fla., Augusta, Ga. and Murfreesboro, Tenn. were caught reusing unsterilized colonoscopy equipment on patient after patient. At least 10 veterans later tested positive for hepatitis as a result.
In a breath-taking display of incompetence, staffers had been sterilizing colonoscopy tubes at the end of each day, according to a VA statement, rather than after each use.
VA officials then failed to inform veterans affected – claiming they couldn’t because the records were locked away in a safe that they controlled – an assertion legislators found ‘almost impossible to believe.’
At the urging of the House Veterans Affairs Committee, the Miami VA center was so poorly run that they called for the removal of the hospital’s director, Mary Berrocal, and her deputy, Nevin Weaver. The two were finally forced out in November 2012 as a result. However, the VA isn’t much on holding executives accountable: Berrocal is still a director in the Miami VA system, and Weaver is still listed on the VA Website as the director of the VA Sunshine Healthcare Network, VISN 8 as of this writing.
John Vara, another Miami VA senior executive who was ‘admonished’ with a letter of reprimand that stays in his record for up to two years, was reassigned to the Palm Beach VA system as chief of staff for education and research.
Additionally, the New York Times reported on a “rogue” cancer unit at the Philadelphia VA Center that botched 92 of 116 prostate cancer ‘seeding’ procedures, hid the matter from investigators, and falsified records to cover the problem.
The unit also continued to seed prostate patients with radioactive particles even though the equipment measuring the radioactivity dose was broken – and the radioactivity safety unit at the hospital knew this for over a year.