Report: VA Facilities Improperly Sterilized Colonoscopy Equipment
An internal investigation out today finds that fewer than half of Veteran's Affairs facilities selected for random inspections had properly sterilized medical equipment used to perform colonoscopies, despite orders to comply with safety guidelines.
The Veterans Affairs inspector general report(pdf) follows revelations that VA hospitals in Florida, Georgia and Tennessee possibly exposed 10,320 veterans to hepatitis B, hepatitis C or HIV by not properly cleaning equipment. As of today, 13 of those veterans have tested positive for hepatitis B, 34 for hepatitis C and six for HIV, according to the VA.
The investigation focused on the sterilization of reusable flexible fiberoptic endoscopes (FFEs), which must be thoroughly rinsed and flushed after use and then stored in a dry, well-ventilated area. Any deviation from the sterilization process puts future patients at risk of infection, according to the report.
VA investigators visited the three medical facilities and made random, unannounced visits to 42 other medical centers in recent months to evaluate procedures.
"The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure," the report concludes.
Investigators unveiled their findings this morning at a House Veterans' Affairs committee hearing on the matter, where lawmakers sharply criticized the department.
Committee Chairman Bob Filner (D-Calif.) praised the VA for its transparency on the issue, but warned, "There will be a public accounting of this situation."
"There is no question that shoddy standards -- systemic across the VA -- put veterans at risk and dealt a blow to their trust in the VA," Rep. Harry E. Mitchell (D-Ariz.) said at the hearing. "And I’ll say it again, whether or not any veterans contracted illnesses from these procedures, it is outrageous that they even have to worry about that possibility."
In a statement, VA Secretary Eric K. Shinseki said he remains personally committed to the well-being of the nation's veterans.
"It is unacceptable that any of our veterans may have been exposed to harm as a result of an endoscopic procedure. When we discovered this problem, stemming back to 2003, I initiated an internal, national review process to evaluate the standard of health care for our Veterans."
In the past week, the department has taken several steps to ensure that employees and supervisors are trained and qualified to handle endoscopy equipment, according to officials. By the end of July, the department will make unannounced inspections of facilities using the equipment, ensuring that each facility is fully qualified. It will also undertake a two-year review of endoscopy procedures eventually requiring that the work of those who perform endoscopy tasks be reviewed everyday by other colleagues.
The internal report noted that the VA is not alone in reporting problems with endoscopy procedures: Private hospitals in California and Pennsylvania have notified thousands of patients in recent years after similar concerns.
| June 16, 2009; 5:31 PM ET
Categories: Agencies and Departments, Oversight
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