Leaked VAOIG report states only 43% of VA facilities had proper training and guidelines in place for endoscopic procedures.

by Larry Scott, VA Watchdog dot Org

This is one of those times when I just have to say, "I told you so." 

The VA did not release the self-reports from their facilities about how endoscopic procedures were conducted, and what training and protocols were in place for a very good reason.

In March of this year I wrote:

What we don't know could fill volumes.

Now, we are waiting for the VA to report on the self-reports from the facilities who perform colonoscopies... if they ever release it at all.

A VA spokesperson was quizzed on the possibility of a nationwide problem and replied, "We don't know for certain."

Neither do veterans...which presents a problem.

It appears VA facilities had different procedures for cleaning equipment, or had the same procedures but didn't follow them.

It appears VA facilities are using different self-reporting procedures about how they cared for the equipment, or had the same self-reporting guidelines but weren't following them.

As you can see, the number of variables takes the number of possibilities off the chart.

At that time I called for all vets who have had an endoscopic procedure in the past ten years to be screened for hepatitis and HIV.

Some pooh-poohed that idea.  How about now?

With 57% of VA facilities not in compliance, you might want to think about that screening.

And, if the VA really takes their charge to care for veterans seriously, they will call for an immediate nationwide screening program ... but don't bet the mortgage on that.

We should have the VAOIG report soon ... along with reports from the upcoming hearing.

All contaminated equipment information is here.

-------------------------

VA inspections show continued flaws

By KIMBERLY HEFLING and BEN EVANS

WASHINGTON (AP) — Fewer than half of Veterans Affairs centers given a surprise inspection last month had proper training and guidelines in place for common endoscopic procedures such as colonoscopies — even after the agency learned that mistakes may have exposed thousands of veterans to HIV and other diseases.

The findings, from the VA's inspector general and obtained by The Associated Press, suggest that errors in colonoscopies and other minimally invasive procedures performed at VA facilities may be more widespread than initially believed.

The report is slated to be released Tuesday at a hearing before a House Veterans Affairs subcommittee, in which VA officials are scheduled to take questions. Rep. Harry Mitchell, D-Ariz., who will chair the hearing, on Monday called the situation a "damaging blow to the trust veterans place in the VA."

Mitchell said in a statement he wants to learn what changes have been put in place to prevent similar mistakes.

Howard McIntyre, commander at one of two Disabled American Veterans chapters in Augusta, Ga., called the findings "disturbing" and said "there shouldn't have been any low level of training at all."

"As soon as it was caught, the training should have been stepped up instantly," the 67-year-old Navy veteran said. Medical care for veterans, he said, "shouldn't be any less than perfect, because these are lives we're talking about."

The random inspections were conducted May 13-14 at 42 VA medical centers around the country. They found that just 43 percent of the centers have standard operating procedures in place and have properly trained their staffs for using endoscopic equipment.

The investigation comes months after the discovery of a mistake at Murfreesboro, Tenn., led to a nationwide safety campaign at the VA's 153 medical centers calling attention to potential infection risks from improperly operating and sterilizing the equipment.

Along with Murfreesboro, the agency has said mistakes were identified at a Miami center and at an ear, nose and throat clinic in Augusta. In February the agency started warning about 10,000 former patients at those facilities, some who had colonoscopies as far back as 2003, to get blood tests for HIV and hepatitis.

As of Friday, the VA 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. But there is no way to prove whether the infections came from VA procedures, and some experts say most or all of the infections probably already existed. The VA says the chance of infection was remote.

Agency spokeswoman Katie Roberts did not respond to a request for comment on the report.

Sen. Richard Burr of North Carolina, the lead Republican on the Senate Veterans Affairs committee, said "too many questions surrounding the VA's handling of this issue remain unanswered."

The VA has acknowledged that the mistakes were caused by human error.

In Murfreesboro, officials believe use of an incorrect valve may have allowed body fluid residue to transfer from patient to patient, possibly for more than five years since the equipment was installed in 2003.

In Miami, a tube that was supposed to be cleaned after each colonoscopy was instead cleaned at the end of each day, affecting patients between May 2004 and March 2009. And in Augusta, the ENT scopes used for looking into the nose and throat weren't properly cleaned, affecting patients between January 2008 and November 2008.

Since VA reported those mistakes, a key question has been whether they might have been repeated at other facilities using similar equipment.

Associated Press writer Russ Bynum in Savannah, Ga., contributed to this report.

-------------------------

TOPICS: veterans, veterans' benefits, VA, Department of Veterans' Affairs, contaminated equipment, endoscopic, hepatitis B, hepatitis C, HIV