Olean General Alerts Patients to Possible Insulin Pen Reuse

Olean General Hospital in Olean, N.Y. announced today that a careful internal review of hospital insulin pen use raised the possibility that their reuse may have occurred with some patients during the period from November 2009 to Jan. 16, 2013.

The hospital has not identified a single patient who ever received an insulin injection from another patients insulin pen. Hospital officials also emphasized there is no documentation at this time of the transmission of any bloodborne infections during the stay of any patient who received insulin from the pens during this period.

Nonetheless, hospital officials recommend, as a precautionary measure, that those individuals who received insulin from an insulin pen at Olean General Hospital during the time period be tested for hepatitis B, hepatitis C, and HIV. The letter to patients also recommends they be retested for HIV three months after their last insulin pen injection at Olean General Hospital and for hepatitis B and hepatitis C six months after their last insulin pen injection at the hospital.

Olean General Hospital, a member of Upper Allegheny Health System, is mailing letters today to 1,915 patients hospitalized at Olean General since November 2009 who received insulin pen injections while at the hospital.

The hospital, which has 186 beds and approximately 280 nurses, has established a call center 716-375-7590 or 1-888-980-1220 staffed from 7 a.m. to 8 p.m. seven days a week. Patients receiving letters are asked to call to coordinate an appointment for testing or to speak with a nurse at the call center if they have questions of any kind. There will be no charge for any screenings, testing, or counseling provided by Olean General Hospital.
Reusable insulin pens have never been used at Bradford Regional Medical Center, also a member of Upper Allegheny Health System and have been removed from use at Olean General Hospital.

Recent news stories brought to light problems with the inappropriate reuse of insulin pens at the Veterans Administration Hospital in Buffalo, says Upper Allegheny Health System president and CEO Timothy J. Finan. This situation prompted Olean General Hospital to initiate its own review and audit of the use of insulin pens at the hospital. Interviews with nursing staff indicated that the practice of using one patients insulin pen for other patients may have
occurred on some patients. These pens are used in hospitals across America, and I want to emphasize that we have been unable to identify any specific patients where this occurred and we have no indication of any infections as a result of their use at Olean General Hospital. Additionally, the issue here does not involve reuse of insulin pen needles. We are certain that insulin pen needles
were not reused because Olean General Hospital has always used special safety needles that cannot be used for more than a single injection. The insulin pen is designed so that it cannot deliver a second dose of insulin with the same needle.

Finan adds, "We are most apologetic for the inconvenience and concern this matter may cause to our patients. The hospital proactively brought these potential concerns to the attention of the New York State Department of Health, and is working with the department as we conduct our review. I want to emphasize that we have been unable to identify a single hospitalized patient
who ever received an insulin injection from an insulin pen that had been used on another patient. Regardless, to the extent there may be a chance, however remote, that any patient was provided insulin from an insulin pen other than their own, Olean General Hospital has decided to be proactive and aggressive with respect to notification of our patients. We are very aware that while the risk of infection from insulin pen reuse is extremely small, cross-contamination from an insulin pen is possible.

Insulin pens are devices that contain a reservoir of insulin or an insulin cartridge. They are intended for single person use only, but are designed to provide a patient with multiple insulin injections. The needle on the insulin pen is removable, allowing reuse of the chamber after the insertion of a new sterile needle for each use.

Reports in the media said single insulin pens at the Buffalo Veterans Administration Medical Center were used on multiple patients instead of a single patient. Insulin pens are used at thousands of hospitals across America and also by diabetics at home. The concern is that a pens insulins cartridge can potentially become contaminated with biologic material from one patient after an insulin injection. If reused on another patient, it can theoretically transmit infection, even after installation of a new sterile needle, to that patient.

The risk of potential infections is considered extremely low, as insulin pens use a small needle with small volume exposure, not involving visible blood and not entering a vessel. Nevertheless, there may be a very small risk that some patients could have been potentially exposed to certain bloodborne infections such as hepatitis B virus, (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).

To summarize, Olean General Hospital has:

- Initiated an internal audit of the use of insulin pens;
- Reported a concern about potential inappropriate use of insulin pens to the New York State Health Department;
- Sent a letter to all hospitalized patients who received insulin pen injections from November 23, 2009 to January 16, 2013;
- Set up a special number for patients to call to coordinate testing or to speak with a nurse if they have questions;
- Discontinued use of insulin pens;
- Reviewed and reinforced all policies and procedures in relation to all insulin injections;
- Notified the media of the potential misuse of insulin pens.

Source: Olean General Hospital