Report Summary

Title: Healthcare Inspection - Review of VHA Follow-Up on Inappropriate Use of Insulin Pens at Medical Facilities
Report Number: 13-01987-263
Issue Date: 8/1/2013
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 how VHA followed up on the inappropriate use of insulin pens at the VA Western New York Healthcare System, Buffalo, NY (the Buffalo facility), and to determine what controls the Veterans Health Administration (VHA) has in place to minimize the risk of other incidents involving insulin pens and similar devices. We conducted the inspection at the request of the Ranking Member, Senate Committee on Veterans’ Affairs.
Although two other VHA facilities reported isolated incidents of nurses using insulin pens on multiple patients, we found no evidence of widespread, systemic reuse of insulin pens on multiple patients. Further, we found that VHA has processes in place to identify important patient safety alerts and disseminate this information to facility managers and numerous policies and procedures in place to address infection prevention.
We recommended that the Under Secretary for Health implement procedures to ensure that future VHA internal assessments resulting from adverse events include clear guidance to facilities on minimal required steps and supporting documentation; require facilities to develop processes for assessing the risks and benefits of adopting new medical products or devices that may require significant changes in nursing procedures; and ensure that facility nursing education departments are sufficiently staffed to provide comprehensive and ongoing nursing education, especially when adopting new medical products or devices that may significantly change nursing procedures.
The Under Secretary for Health concurred with our findings and recommendations and provided an acceptable action plan