Report Summary

Title: Healthcare Inspection – Inappropriate Use of Insulin Pens, VA Western New York Healthcare System, Buffalo, New York
Report Number: 13-01320-200
Issue Date: 5/9/2013
City/State: Buffalo, NY
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
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.