Over 700 veterans treated at the Buffalo VA Hospital could have contracted HIV, hepatitis B or hepatitis C from insulin pens that were intended to be used only once. Though some commend the VA Hospital for its transparency, many more are understandably shocked about the fact that the oversight had occurred for more than two years.

The insulin delivery systems for patients with diabetes could have been reused between October 19, 2010 and November 1, 2012, the Buffalo News reports. This information was obtained from the hospital's letter to Congress.

The oversight was discovered during a routine pharmacy inspection in November 1 of last year. Someone noted that insulin pens were sitting in a supply cart without labels, indicating that they may have been reused. The hospital said that they took immediate action to make sure that the insulin pens were then being used according to pharmaceutical standards.

Since the discovery, all of the 570 patients who were treated with insulin pens and who are still alive will be asked to return to the hospital for blood testing. There will be no co-pay or charge for the testing. The hospital is sending out letters to those affected, as well as setting up a call center to handle questions from concerned patients and their families. The hospital said in a draft of the letter that it was impossible to know whether patients had received injections from improperly labeled insulin pens or not.

The hospital says that the risk of infection is low. Insulin pens may be disposable or reusable if used with different needles, according to the Associated Press. However, even then, the pens are not recommended for use with more than one patient. Indeed, nurses at the hospitals changed the needles before use. Even with a fresh needle, however, contamination may have still occurred if bodily fluid flowed back into the pen from the needle. VA officials say that the risk of contamination would be far greater if nurses used the same needles on multiple patients.

The VA National Center for Patient Safety is implementing a patient safety alert so that the mistake is not repeated.