Senator Eliot Shapleigh - El Paso, Texas

FORT BLISS -- Beaumont Army Medical Center is contacting 2,114 diabetes patients who have been treated at the hospital since August 2007 because they may be at risk for developing a blood-borne disease such as hepatitis or HIV.

The diseases could have been transmitted through an error in the way that insulin was injected into patients, Col. James Baunchalk, commander of Beaumont Army Medical Center, said Thursday morning.

Diabetes patients at the center are treated with insulin injection pen systems, which are designed for repeated use on a single patient.

Though a sterile needle is used for each injection on every patient, the pen systems, which contain a reservoir of insulin for multiple doses, were possibly used by more than one patient through the end of January.

"At this particular point in time, we really can't quantify how widespread this practice was at our institution," Baunchalk said. "And so quite honestly, it's hard for us to tell whether it's two, 20 or 2,000 who may potentially have been exposed."

Baunchalk said the error in administering insulin with the multi-dose pen systems came to light Jan. 30 when two nurses at Beaumont Army Medical Center reported concerns about patients using the same injection pens.

An investigation was launched, and the staff has been retrained on the appropriate use of the insulin injection pens. A toll-free hot line also was launched to answer questions or concerns from the public, Baunchalk said.

The incident at Beaumont prompted Army Surgeon General Lt. Gen. Eric B. Schoomaker to order a review of the use of the insulin pens throughout the branch of service and drew unease and calls for a thorough investigation from area congressmen.

"William Beaumont Army Medical Center has an obligation to provide the men and women of the military, veterans, and their families with the highest quality of care," U.S. Rep. Silvestre Reyes, D-Texas, wrote in a statement. "This incident is inexcusable and clearly does not rise to the standard of excellence that is expected of the Department of Defense."

Reyes, chairman of the House Intelligence Committee, said he was assured by the Schoomaker that the risk of exposed patients developing a blood-borne disease was low.

Fifteen or fewer patients have been potentially exposed to blood-borne diseases at the Jones Army Community Hospital at Fort Polk, La., because of improper administration of insulin. The insulin injection pen system is used at nine military hospitals or clinics, Army officials said.

U.S. Rep. Harry Teague, D-New Mexico, wrote to Baunchalk on Thursday asking for answers about how the insulin injections came to be administered incorrectly.

Baunchalk told the El Paso Times that transmitting a blood-borne disease from one patient to another using the same insulin injection pen was unlikely.

Lt. Col. Sandy Lufon, chief of preventive medicine at Beaumont, said one study has shown that blood was found to have traveled via the needle of the injection pens back into their reservoir of insulin at a rate of 4 percent.

Baunchalk said the 2,114 diabetes patients treated at Beaumont must be contacted so Army officials can begin testing to determine whether any adverse health effects have occurred from the incorrect administration of insulin.

He added that Beaumont on Thursday did not have enough data on hand to determine whether any of the 2,114 diabetes patients already had hepatitis or HIV.

This is not the first case of patients at Beaumont being exposed to a blood-borne disease.

In 2004, 15 people might have contracted hepatitis C from a Beaumont nurse who was arrested in March 2008 and charged with three counts of assault, three counts of aggravated assault and three counts of possessing a controlled substance.

According to a lawsuit filed by one of the 15 patients who claimed to have contracted hepatitis C, former Beaumont nurse Jon Dale Jones contracted the disease while working at the Army hospital, where he allegedly stole the painkiller Fentanyl, which he administered to himself before giving it to patients.

In the more recent case, Baunchalk said it will take time to determine how staffers implemented the wrong procedures for using the insulin pens. He also said the center is determined to restore the public's confidence in its services.

"We deeply regret that this situation has occurred and we are absolutely committed to delivering the very best of health care to those folks who chose to entrust us with their needs," Baunchalk said.

"We have taken aggressive steps to make sure that we have corrected this practice. We want to continue to work with (our patients) and for them and hopefully we will earn their trust back at William Beaumont and what we can do for them," he said.