The discovery of possible re-use in Olean was triggered by awareness of the troubles at the Buffalo VA Medical Center, where more than 700 patients, over a two year period may have been exposed to HIV or hepatitis.
Olean General is mailing letters to almost 2,000 patients who may have received insulin pen injections at the hospital, warning them of the same issue that on Tuesday triggered a federal probe at the VA in Buffalo .
For Questions, Call
716-375-7590 or 1-888-980-1220
from 7 a.m. to 8 p.m.
Patients receiving letters from Olean General are asked to call to coordinate an appointment for testing or to speak with a nurse at the call center if they have questions of any kind. There will be no charge for any screenings, testing, or counseling provided by Olean General Hospital.
“This situation prompted Olean General Hospital to initiate its own review and audit of the use of insulin pens at the hospital. Interviews with nursing staff indicated that the practice of using one patient’s insulin pen for other patients may have occurred on some patients,” said Timothy Finan, CEO of Olean hospital's parent company, The Upper Allegheny Health System.
The situation comes at a time when when health officials nationwide are raising concerns over the re-use of the insulin pens, in ways that could sometimes transmit blood borne illness or disease.
"This just shouldn't happen, but it does," Dr. Melissa Schaefer of the CDC said Monday, "and I think the incidents we hear about are likely underreported.
In this latest event, the Olean hospital is urging patients who received insulin at the hospital in the past three years to be tested for Hepatitis or HIV. They are mailing letters today to 1,915 patients hospitalized at Olean General since November 2009 who received insulin pen injections while at the hospital.
As a precautionary measure, the Olean hospital is recommending that anyone who received received insulin from an insulin pen at Olean General Hospital between November 2009 to January 16, 2013 be tested for hepatitis B, hepatitis C, and HIV.
"Hospital officials also emphasized there is no documentation at this time of the transmission of any blood borne infections during the stay of any patient who received insulin from the pens during this period, " Olean officials said in a prepared statement (below)
Even when the needles are changed-- as they were at the VA-- the stored insulin could have been contaminated by a back flow of blood with each use, experts say.
"There is a very small chance that some patients could have been exposed to the hepatitis B virus, the hepatitis C virus or HIV, based on practices identified at the facility," a Friday memo from the VA to the region's congressional representatives said
Federal health agencies have been warning against sharing insulin pens for several years. The Food and Drug Administration 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 last year came amid continued reports of the practice nationwide .
"Reuse of insulin pens for more than one patient essentially is akin to syringe reuse," The CDC's Schaefer said.
"You can get back flow of blood into that syringe or cartridge that contains the insulin and then you potentially expose others patients. And changing the needle wouldn't make it safe for multi-patient use."
Ignorance of the danger may be a factor, experts said, with hospital employees mistakenly viewing the pens like multi-dose drug vials that are meant to safely supply more than one patient if each dose is drawn with a new needle.
"As we get new technology, it's just re-educating personnel," Schaefer said
Verbatim from Olean General:
Olean General Hospital announced today that a careful internal review of hospital insulin pen use raised the possibility that their re-use may have occurred with some patients during the period November 2009 to January 16, 2013.
The hospital has not identified a single patient who ever received an insulin injection from another patient’s insulin pen. Hospital officials also emphasized there is no documentation at this time of the transmission of any blood borne infections during the stay of any patient who received insulin from the pens during this period.
Nonetheless, hospital officials recommend, as a precautionary measure, that those individuals who received insulin from an insulin pen at Olean General Hospital during the time period be tested for hepatitis B, hepatitis C, and HIV. The letter to patients also recommends they be retested for HIV three months after their last insulin pen injection at Olean General Hospital and for hepatitis B and hepatitis C six months after their last insulin pen injection at the hospital.
Olean General Hospital, a member of Upper Allegheny Health System, is mailing letters today to 1,915 patients hospitalized at Olean General since November 2009 who received insulin pen injections while at the hospital.
The hospital, which has 186 beds and approximately 280 nurses, has established a call center – 716-375-7590 or 1-888-980-1220 – staffed from 7 a.m. to 8 p.m. seven days a week. Patients receiving letters are asked to call to coordinate an appointment for testing or to speak with a nurse at the call center if they have questions of any kind. There will be no charge for any screenings, testing, or counseling provided by Olean General Hospital.
Reusable insulin pens have never been used at Bradford Regional Medical Center, also a member of Upper Allegheny Health System and have been removed from use at Olean General Hospital.
“Recent news stories brought to light problems with the inappropriate re-use of insulin pens at the Veterans Administration Hospital in Buffalo,” said Upper Allegheny Health System President and CEO Timothy J. Finan. “This situation prompted Olean General Hospital to initiate its own review and audit of the use of insulin pens at the hospital. Interviews with nursing staff indicated that the practice of using one patient’s insulin pen for other patients may have occurred on some patients.”
“These pens are used in hospitals across America, and I want to emphasize that we have been unable to identify any specific patients where this occurred and we have no indication of any infections as a result of their use at Olean General Hospital,” he said. “Additionally, the issue here does not involve reuse of insulin pen needles. We are certain that insulin pen needles were not reused because Olean General Hospital has always used special safety needles that cannot be used for more than a single injection. The insulin pen is designed so that it cannot deliver a second dose of insulin with the same needle.”
“We are most apologetic for the inconvenience and concern this matter may cause to our patients,” Finan said.
“The hospital proactively brought these potential concerns to the attention of the New York State Department of Health, and is working with the department as we conduct our review,” Finan said.
“I want to emphasize that we have been unable to identify a single hospitalized patient who ever received an insulin injection from an insulin pen that had been used on another patient,” Finan said. “Regardless, to the extent there may be a chance, however remote, that any patient was provided insulin from an insulin pen other than their own, Olean General Hospital has decided to be proactive and aggressive with respect to notification of our patients. We are very aware that while the risk of infection from insulin pen re-use is extremely small, cross contamination from an insulin pen is possible.”
Insulin pens are devices that contain a reservoir of insulin or an insulin cartridge. They are intended for single person use only, but are designed to provide a patient with multiple insulin injections. The needle on the insulin pen is removable, allowing reuse of the chamber after the insertion of a new sterile needle for each use.
Reports in the media said single insulin pens at the Buffalo Veterans Administration Medical Center were used on multiple patients instead of a single patient. Insulin pens are used at thousands of hospitals across America and also by diabetics at home.
The concern is that a pen’s insulin’s cartridge can potentially become contaminated with biologic material from one patient after an insulin injection. If reused on another patient, it can theoretically transmit infection, even after installation of a new sterile needle, to that patient. The risk of potential infections is considered extremely low, as insulin pens use a small needle with small volume exposure, not involving visible blood and not entering a vessel. Nevertheless, there may be a very small risk that some patients could have been potentially exposed to certain blood borne infections such as hepatitis B virus, (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).
Summary of Actions Taken by Olean General Hospital: