关键词：胰岛素笔；医疗保健机构；医药
摘 要：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. In late October 2012, the facility Chief of Pharmacy discovered three insulin pens designed for single-patient use onlywith no patient labels in a supply drawer of a medication cart. Facility officials subsequently found three more pens without patient labels in medication carts on three other inpatient units, and, when queried, several nurses reportedly acknowledged using the pens on multiple patients. Inappropriately using single-patient use insulin pens on multiple patients may potentially expose patients to bloodborne pathogens.