IG Reports on VA Endoscopes

Inspector General Completes Study of VA Endoscopic Programs

WASHINGTON – The Department of Veterans Affairs (VA) Office of Inspector General inspected every VA medical site with endoscopic equipment, independently verifying the success of a national program VA instituted to ensure safe and sterile procedures for reprocessing endoscopic equipment across the country.

“VA’s top priority is to provide the highest quality care to the Veterans of this Nation,” said Acting Under Secretary for Health Dr. Gerald M. Cross. “This report shows VA’s unparalleled quality assurance programs identified a risk and successfully corrected that risk on a national scale.”

The VA Office of Inspector General report, dated September 17, 2009, shares findings from 129 medical sites inspected across the country. Only one discrepancy was found, a typographical error in certification paperwork.

In late 2008 and early 2009, VA found that inconsistencies in the sterilization of endoscopes at three medical centers led to possible infection risks among 10,000 patients. VA facilities rapidly notified patients of the risk and offered testing.  Since that time, VA has been able to contact over 99 percent of these patients.  Although fifty-six patients potentially screened positive for infections, though it is uncertain whether the endoscopes are the source.  The national information line at 1-877-345-8555 is available for patients and their families.

VA instituted a national review of facilities in February, 2009, to ensure all VA medical sites are trained on proper endoscope use and cleaning procedures.  VA then established a new policy for the reprocessing of reusable medial equipment, including certification of staff, to prevent future incidents.  VA has also currently taken over forty disciplinary actions related to this event.

Following the completion of this national effort, the Office of the Inspector General inspected every VA medical site with endoscopic equipment for compliance with manufacturers’ instructions and VA’s national policy on endoscopic equipment and procedures.  This report is found at:

http://www.va.gov/oig/54/reports/VAOIG-09-02848-218.pdf.