VA Addresses Failures of Contaminated Equipment Use

Washington, D.C. – On Tuesday, June 16, 2009, the House Veterans’ Affairs Oversight and Investigations Subcommittee, led by Chairman Harry Mitchell (D-AZ), conducted a hearing to evaluate endoscopy procedures used by the Department of Veterans Affairs (VA).  The hearing focused on VA reports of improper reprocessing, incorrect usage, and substandard cleaning of endoscopic equipment at Murfreesboro, Tennessee; Augusta, Georgia; and Miami, Florida.  The hearing also focused on the findings of a recently released VA Office of Inspector General (VAOIG) report following unannounced visits to more than 42 facilities operated by the Veterans Health Administration (VHA).

“Exposing our veterans to that type of risk is unacceptable, and frankly I’m outraged at the thought of them having to worry about the possibility of being infected,” Chairman Mitchell said.  “The VA now has to work to implement standardized procedures and training to ensure mistakes like these will never happen again. It must work harder and longer to regain the trust of the veterans it serves and care for those who have been exposed.”

VHA employees exposed veterans to possible harm by using a wrong valve, not cleaning parts of endoscopic equipment correctly, using the wrong disinfectant to clean equipment, failure to reprocess the flush tubing leading to the scopes correctly, and connecting water tubing in the middle of procedures and not in the beginning.  All mistakes were human error due to lack of enforcement of proper procedures.  Of the more than 10,000 veterans possibly affected, VA has reported that six veterans taking the follow-up blood checks tested positive for HIV, 34 tested positive for hepatitis C, and 13 tested positive for hepatitis B. 

In response to reports of incorrect usage and cleaning of medical instruments, VA National Center for Patient Safety issued an alert that highlighted reprocessing issues with colonoscopes and required certification by January 7, 2009, for compliance with alert requirements that included staff training review.  On February 4, 2009, VHA announced ‘Endoscopy Step Up Week’ to be conducted March 8-14.  On February 9, 2009, VHA issued a directive to facilities on the proper use and reprocessing of reusable medical equipment.

The VAOIG traveled to each of the three facilities that initially reported incorrect use and cleaning of endoscopes.  Investigators assessed the conditions at the facilities and evaluated the risk veterans are exposed to as a result of improper procedures.  Further, VAOIG conducted unannounced onsite visits at 42 randomly selected VHA hospitals to inspect facilities and assess current standard operating procedures for reprocessing reusable equipment.  It was found that fewer than half of the health care facilities given surprise inspections were compliant with standard operating procedures and competent in accordance with the February directive from VHA.

A June 16, 2009, VAOIG report entitled “Healthcare Inspection: Use of Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities”
contained the following conclusion: “Facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans.

Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care.  The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure.”

Dr. William Duncan, Associate Deputy Under Secretary for Health for Quality and Safety, offered the following statement: “Because of the quality and patient safety programs VA has built over the past several years, we discovered the problem, identified the patient population at risk, proactively notified them, and began robust testing, counseling and treatment.  The reprocessing issues identified at our facilities were identified and announced by VA, not by an outside group.  We have kept Veterans Service Organizations, the media, and Congress informed about this issue.” 

VA is operating a toll-free hotline to provide information to veterans at (877) 575-7256. 

“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 Bob Filner (D-CA), Chairman of the House Committee on Veterans’ Affairs.  “There will be a public accounting of this situation.  I am encouraged that the VA is being transparent, coming forward and bringing this to light.  When mistakes are made, honesty and truthfulness are the only way to begin to
rebuild trust with the public."    

Witness List

Panel 1:

*       John D. Daigh, Jr., M.D., CPA, Assistant Inspector General for
Healthcare Inspections, Office of Inspector General, U.S. Department of Veterans Affairs

  accompanied by:

*       Jerome Herbers, M.D., Associate Director of Medical Consultation
and Review, Office of Healthcare Inspections, Office of Inspector General, U.S. Department of Veterans Affairs

*       George Wesley, M.D., Director of Medical Consultation and
Review, Office of Healthcare Inspections, Office of Inspector General, U.S. Department of Veterans Affairs

*       Limin Clegg, Ph.D., Director of the Biostatistics Division,
Office of Inspector General, U.S. Department of Veterans Affairs

Panel 2:

*       William E. Duncan, M.D., Ph.D., MACP, Associate Deputy Under
Secretary for Health for Quality and Safety, Veterans Health Administration, U.S. Department of Veterans Affairs

  accompanied by:

*       James P. Bagian, M.D., PE, Chief Patient Safety Officer,
National Center for Patient Safety, Veterans Health Administration, U.S.
Department of Veterans Affairs

*       Nevin Weaver, FACHE, Director, VA Sunshine Healthcare Network,
VISN 8, Veterans Health Administration, U.S. Department of Veterans Affairs

*       Lawrence A. Biro, Director, VA Southeast Network, VISN 7,
Veterans Health Administration, U.S. Department of Veterans Affairs

*       Joseph Pellechia, M.D., FACP, Interim Network Chief Medical
Officer and Chief of Staff, Huntington VA Medical Center, Veterans Health Administration, U.S. Department of Veterans Affairs

*       John R. Vara, M.D., Chief of Staff, Miami VA Medical Center,
Veterans Health Administration, U.S. Department of Veterans Affairs

*       Juan A. Morales, RN, MSN, Director of the Tennessee Valley
Healthcare System, Veterans Health Administration, U.S. Department of Veterans Affairs

*       Rebecca J. Wiley, Director of the Charlie Norwood VA Medical
Center, Veterans Health Administration, U.S.  Department of Veterans Affairs

*       Mary Berrocal, MBA, Director of the Bruce W. Carter VA Medical
Center, Veterans Health Administration, U.S. Department of Veterans Affairs

Prepared testimony for the hearing and a link to the webcast from the hearing is available on the internet at this link:
http://veterans.house.gov/hearings/hearing.aspx?newsid=417