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Report: VA Facilities Improperly Sterilized Colonoscopy Equipment

By Ed O'Keefe

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.

By Ed O'Keefe  | June 16, 2009; 5:31 PM ET
Categories:  Agencies and Departments, Oversight  
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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.

Posted by: | June 16, 2009 10:54 PM | Report abuse

Taking it up the backside with dirty instruments- an apt description of what was done to all Americans during the Bush years.

Posted by: hairguy01 | June 17, 2009 12:43 AM | Report abuse

This would not of happened if the VA actually had enough medical staff, and better management.

For decades our government has done a very good job of saving taxpayers’ money with inadequate Veterans Affairs funding.

President Obama recently made excellent leadership appointments to Veterans Affairs. Even with their proven leadership abilities, and impeccable credentials, both Secretary Eric Shinseki and Deputy Secretary W. Scott Gould are facing the cumulative inadequacies of decades past. The tiny fuse of overmedication that has kept this whole VA system operational for 30-some years now desperately needs to be replaced with major re-wiring.

This young generation of veterans should not have to experience the palliative treatment of health care most veterans using the VA have experienced for decades. It would be great to see the VA step into the 21st century as the leader in world-class health care.

But after decades of under-funding, this proposed new VA budget is not enough. For our new leadership to achieve its full potential along with world-class VA health care, a one-time, additional funding of at least $17 billion is desperately needed.]

The VA has many good doctors working there who will feel much relief to actually have the opportunity to treat their patients instead of just medicating their symptoms.

Posted by: pattipace7 | June 17, 2009 5:22 AM | Report abuse

After 41 years of being blacklisted for employment in the United States because of my honorable combat service in Vietnam and watching other veterans become homeless or die because of delays in the treatment of service connected injuries, I am not convinced that this further mortality through HIV and hepatitis infections was not intentional. The DVA receives plenty of money, and the civil servants want it for themselves. That is why the DVA uses its money for veterans' health care to hire lawyers rather than medical personnel. Each delay in treating a service connected injury and each denial leading to a long appeal process increases the chances that the veteran will die, and each veteran who dies before his time saves the DVA tens of thousands of dollars in future health care. Filner's Committee needs to review the evidence that I have accumulated about government fraud against veterans, but it does not even provide an e-mail address for veterans to send it information.

Posted by: cwheckman | June 17, 2009 1:15 PM | Report abuse

Here's some more information on the VA scope scandal:
VA Blasted At Hearing On Contamination Scandal:

Posted by: Cynthia111 | June 17, 2009 3:42 PM | Report abuse

My-My, what do you expect from the "govt" Hospital! My brother had surgery just last week and a VA Hospital and was told the cancer was located at the top right on his colon. After the surgery, these VA Doc's came in and announced that the x ray showed that the cancer was on the top left! It took an outside Specialist to read the x-ray correctly, which made the hold family feel better. Now, it has always been known that, although you may have finished medical school, which can be done with an "A", "B", "C" and sometimes "D", BUT, the "top" students go on to the "top" Hospitals, and that leaves the rest to work at places like the Govt. VA hospitals. With that said, why be surprised at anything happening there.

Posted by: Chrisjj1948 | June 18, 2009 2:48 AM | Report abuse

The post should be ashamed of printing and post an article that is so factually incorrect. The writer and editor obviously did not read the IGs report nor did they listen to any of the congressional testimony. Worse they could have known this was wrong but chose to print anyway. Who ever notices the corrections section anyway? The IG was clear that they saw no indication that scopes were being processed incorrectly during their unannounced audits. Half the sites were not able to produce writen competencies and SOPs for each product as they should have. Go to other news sites if you want to see articles that are written by people who actually listened to the testimony.

Posted by: nbeck1 | June 18, 2009 9:14 AM | Report abuse

There were three hospitals in which the standard for processing endoscopes was not followed. Having worked in both the pulic and private sector I can assure you the level of care at the VA exceeds the standard of care in the private sector. The report of about 50% of VA's failing a spot inspection is misleading. The vast majority of the findings were for not following specific VA policies. Those policies are far stricter that those at any private facility or requirements of The Joint Commission (TCJ). TJC requires that the manufacturer's instructions be followed for reprocessing endoscopes. Most policies simply state "follow manufacturer's instructions".The NEW VA policy requires the every type and model of endoscope used must have a individual Standard Operating Proceedure (SOP) which lists all of the manufacturer's instructions. In addition the manufacture's instructions must be readily available. There must also be a competency assessment for the individuals processing the endoscopes. There must be a seperate competency for every type and model of scope even if they are identical to those of other endoscopes. These are also very new policies and not seen at many facilities. I seriously doubt that there are more that 5% of private sector facilities that could meet VA standards. The VA publisizes accidents while the private sector hides them. Having inspected many facilities performing endoscopies, I have found the VA practices consistantly exceed private facilities.

Posted by: rwbonnema | June 18, 2009 4:39 PM | Report abuse

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