Niagara Gazette

January 31, 2013

Higgins questions VA miscommunication

Staff reports
Niagara Gazette

Niagara Gazette — A local Congressman believes "warning signs" could have prevented an error that may have exposed patients at the Veterans Hospital in Buffalo to infection due to faulty insulin pen use. 

U.S. Rep. Brian Higgins, D-Buffalo and Niagara Falls, on Thursday called for improved communication and coordination among VA officials to better safeguard area vets.

“What we see here is not an isolated incident at the VA but a disturbing pattern of errors and complete lack of adequate prevention measures following repeated red flags,” Higgins said in a release issued by his office. “The more we learn, the more alarming this becomes. We see a very poor track record by the VA to learn from their mistakes and better protect the health and welfare of our veterans.”

In a letter to the secretary of the U.S. Veterans Administration, Higgins outlined a series of warning signs which he said should have prevented the recent medical error at the VA Medical Center in Buffalo that is threatening the health of more than 700 veterans and their families. In his letter, Higgins provided a timeline that detailed what he described as the missed opportunities to correct and prevent risks of hospital acquired infections, including instances dating back years in which unsafe insulin pen injections were reported at VA hospitals in other parts of the country, including a December 2008 report from the VA Southern Nevada Healthcare System, a January 2009 report from a military hospital in Texas that cited single-patient use insulin pens were used on more than 2,000 patients and a January 2012 CDC Clinical Reminder that insulin pens "must never be used for more than one person."

Higgins also cited the numerous resources readily available to medical facilities and providers through the CDC “One and Only” campaign aimed at eliminating outbreaks resulting from unsafe injection practices. 

“There is a structural deficiency in how the VA is receiving these warning from its sister agencies, or how the VA is communicating these warnings to its hospitals across the country," Higgins wrote. "Either is unacceptable. The sad truth is that this lack of attention and action on the part of the VA has resulted in poor care for our veterans and will continue without action."

Higgins also previously wrote to Secretary Shinseki seeking answers and new prevention measures in response to the Buffalo incident. In addition, VA Inspector General recently initiated a review, requested by Higgins, of the circumstances surrounding the reuse of insulin pens at the VA facility in Western New York.