Review of Veterans Health Administration Follow-Up on Inappropriate Use of Insulin Pens at Medical Facilities.

摘要

The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted an inspection to evaluate how the Veterans Health Administration (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 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 to look at issues related to VHAs management of patient safety alerts, new medical products and devices, and infection prevention activities. We prepared a separate report on the specific circumstances of the misuse at the Buffalo facility. VHAs internal assessments following the Buffalo incident did not include clear, standard guidance to facilities on how to perform and document their audits of insulin pen use, and we found no documentation to support their internal reviews and significant variation in how facilities conducted their reviews. However, our onsite work at 4 facilities, including interviews with over 150 nurses, found no evidence of widespread, systemic reuse of insulin pens on multiple patients. The majority of nurses we spoke to understood that insulin pens were intended for single-patient use. Furthermore, on January 17, 2013, VHA generally prohibited the use of multi-dose insulin pens on inpatient units, effective February 4, 2013.