VA officials grilled about improperly sterilized medical equipment

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VA officials grilled about improperly sterilized medical equipment

Lesley Clark - McClatchy Newspapers

June 16, 2009 03:56 PM

WASHINGTON — Several employees at the Miami Veterans Affairs hospital are likely to be disciplined for failing to detect problems with improperly sterilized medical equipment in a case that's enraged members of Congress.

The disclosure of the potential punishments came as federal lawmakers chided the Department of Veterans Affairs for not moving faster to address mistakes that may have exposed thousands of veterans to HIV and hepatitis. A VA Inspector General's report released Tuesday showed that fewer than half of VA medical facilities reviewed during a recent surprise inspection could provide evidence of proper procedures and training, though VA officials had promised Congress prompt action after problems at three VA facilities were disclosed.

"You certainly would think that after the initial discoveries and the directive from the VA that medical directors would make sure that all of their equipment and procedures were brought into line, and yet this investigation shows that many, many did not," said Rep. Bob Filner, D-Calif., the chairman of the House Veterans Affairs Committee. "There will be a public accounting of this situation."

In the Miami case, the hospital gave itself a clean bill of health in January only to discover problems two months later after a more intensive review. Five to 10 employees are likely to face some sort of discipline, ranging from admonishments to suspension without pay. No firings are likely, said John Vara, the Miami hospital's chief of staff.

Top Veterans Affairs officials promised lawmakers they'd redouble efforts to prevent a repeat. VA Secretary Eric Shinseki issued a statement after the hearing that said it was "unacceptable that any of our veterans may have been exposed to harm as a result of an endoscopic procedure."

Shinseki said he was "deeply troubled" by the inspector general's report and was "implementing a new policy requiring each director to verify in writing compliance with VA standing operating procedures."

The VA issued its first alert in December, warning of possible contamination problems with equipment being used in colonoscopies, based on problems at a VA hospital in Murfreesboro, Tenn. Problems later were found with endoscopic procedures at the VA's Augusta, Ga., ear, nose and throat clinic, and with colonoscopies performed in Miami.

However, the inspector general's report said that surprise inspections May 13 and 14 found that only 43 percent of the facilities inspected had appropriate operating procedures in place for endoscopes and could document that staffers had been properly trained.

"I sit here today and still feel a lack of confidence in what veterans are going through," said Rep. Kendrick Meek, D-Fla., who said he was promised several months ago that the situation would be addressed. "I want to know what can I tell my constituents and my veterans who say they can't believe this is still happening."

William Duncan, a VA official in charge of health quality and safety, said the VA was "extremely disappointed" with its performance in the report and was committed to "reducing those adverse affects to the lowest possible level."

The report found that even after problems were detected in Miami, a representative of the equipment maker found "debris" in the equipment "while flushing a colonoscope presumed to be clean." It says that an internal VA board found "serious problems" with the facility's oversight, supervision and training. As recently as April, the board found that the cleaning of the endoscope equipment was "incomplete and not according to . . . manufacturer's instructions."

The report says a team from another VA medical facility and representatives of the equipment manufacturer provided training, and that a follow-up visit by the VA's Infectious Diseases Program office found that technicians "were properly cleaning the endoscopes."

The VA said that six veterans had tested positive for HIV, 34 tested positive for hepatitis C and 13 tested positive for hepatitis B. VA officials said they wouldn't be able to determine whether the infections were the result of the equipment or pre-existing conditions.