We have smaller leaks all the time, you know, a fax number is wrong by a digit, and the number that is loaded into the system is not the pharmacy down the street, but some law firm.

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"On November 1, 2012, officials at the (Veterans Affairs Western New York Healthcare System) reported that while conducting pharmacy inspection rounds on the inpatient units, they discovered that insulin pens intended for individual patient use were found in the supply drawer of the medication carts without a patient label on them, " said the memo, obtained by CNN through the office of U.S. Rep. Brian Higgins, D-New York.

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To simplify matters, he suggested dedicating a single pharmacy clerk to insure prompt service and to set up a system he can experiment against, Toyota-style.

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