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Healthcare Inspection – Inappropriate Use of Insulin Pens, VA Western New York Healthcare System, Buffalo, New York

Report Information

Issue Date
Report Number
13-01320-200
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted an inspection to evaluate the circumstances surrounding the reported inappropriate use of insulin pens at the VA Western New York Healthcare System, Buffalo, New York (the facility). We conducted the inspection at the requests of the Chairmen and Ranking Members of the House Committee on Veterans’ Affairs and the Senate Committee on Veterans’ Affairs, Senator Charles Schumer, and Congressmen Brian Higgins and Chris Collins. This report addresses questions raised by Members of Congress regarding the specific circumstances at the facility. The OIG will issue a separate report addressing broader questions pertaining to insulin pen use at other facilities, as well as Veterans Health Administration (VHA) oversight and follow-up. We recommended that the Under Secretary for Health finalize VHA’s Clinical Operations Guideline for “Implementation of a Large Scale Disclosure Decision” and that the Veterans Integrated Service Network Director review the facts that led to the misuse of insulin pens and take appropriate administrative action. We also recommended that the Facility Director implement a process to ensure the facility’s Medication Use, Nursing Practice, and Commodity Standards Committees and other relevant leadership evaluate the risks and benefits before introducing new medical products or supplies and strengthen nurse education practices when introducing new medical products or supplies and ensure that all nurses are made aware of how to find and use the facility’s nursing practice procedures. The Under Secretary for Health concurred with our findings and recommendations and provided an acceptable action plan.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health finalize VHA's Clinical Operations Guideline for 'Implementation of a Large Scale Disclosure Decision' to include a monitoring process that reflects the urgency of disclosing adverse events to patients.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VISN Director review the facts that led to the misuse of insulin pens and take appropriate administrative action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director implement a process to ensure the facility's Medication Use, Nursing Practice, and Commodity Standards Committees and other relevant leadership evaluate the risks and benefits before introducing new medical products or supplies that require changes in nursing procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director strengthen nurse education practices when introducing new medical products or supplies and ensure that all nurses are made aware of how to find and use the facility's nursing practice procedures.