| VAOIG FINDS
FUNDAMENTAL DEFECTS IN VA HEALTH CARE
On contaminated equipment: The failure
of medical facilities to comply on such a large scale with
repeated alerts and directives suggests fundamental defects in
organizational structure.
by Larry Scott, VA Watchdog
dot Org
The VA's Office of Inspector
General ( VAOIG ) has
finally released their report on endoscopic procedures at VA
facilities.
Healthcare Inspection
Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA
Medical Facilities -- Report Number 09-01784-146, 6/16/2009 |
Summary |
Report (PDF)
In short form: VAOIG conducted
surprise visits to a number of VA facilities. 57% of those
facilities were not in compliance with proper cleaning protocols
for endoscopic devices such as colonoscopes.
In other words, if a veteran had
an endoscopic procedure, there is a better than even chance that
they were exposed to equipment that was not properly cleaned.
Which means, there is a better than even chance that the veteran
may have been exposed to contamination.
This is beyond outrageous!
And, it calls into question the
cleanliness of other equipment used in invasive procedures.
Given the facts in the VAOIG
report, the VA must call for nationwide screening of all veterans
who have had endoscopic procedures in the past ten years.
Anything less is bad medicine and puts veterans' lives at risk.
All information on
contaminated equipment is here.
VAOIG report Summary is below
... be sure to read the entire report at the link provided.
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Executive Summary
Introduction
The VA Office of Inspector General received
requests from the Secretary, Chairmen and Ranking Members of VA
oversight committees, along with individual members of Congress,
regarding the reprocessing of endoscopic equipment at several
specific VA medical centers (VAMCs), and to assess the extent of
related problems throughout the Veterans Health Administration
(VHA). The purpose of the review is to describe the pertinent
events at VAMCs where problems were reported, assess VHA’s
response to the events, and conduct a system-wide evaluation of
current reprocessing practices.
Results
We visited the facilities which had been the
subject of considerable media attention: the Bruce W. Carter VAMC
(Miami) in Miami, FL; the Tennessee Valley Healthcare
System-Murfreesboro campus (Murfreesboro); and the Charlie Norwood
VA Medical Center (Augusta) in Augusta, GA. We reviewed applicable
regulations, policies, procedures, and guidelines.
 Furthermore,
26 inspectors conducted unannounced onsite visits for the total of
42 probability-based randomly selected VHA facilities to examine
pertinent endoscope reprocessing documentation.
Because of the unannounced nature of the
inspections and for cost-efficiency, a stratified clustering
sample design was employed to maximize the number of facilities
that could be inspected in a single day. Two probability-based
random samples of VHA endoscope reprocessing facilities were
selected from the study populations for the unannounced onsite
inspection: one for colonoscope reprocessing and another for ENT
endoscope reprocessing. With probability sampling, each unit in
the study population has a known positive probability of
selection. This property of probability sampling avoids selection
bias and allows use of statistical theory to make valid inferences
from the sample to the study population.
Conclusions and Recommendations
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.
The Clinical Risk Assessment Advisory Board
has been an effective mechanism for providing guidance to VHA
leadership on disclosure of adverse events to veterans.
Recommendation 1:
We recommended that the Acting Under Secretary
for Health ensure compliance with relevant directives regarding
endoscope reprocessing.
Recommendation 2:
We recommended that the Acting Under Secretary
for Health explore possibilities for improving the reliability of
endoscope reprocessing with VA and non-VA experts.
Recommendation 3:
We recommended that the Acting Under Secretary
for Health review the VHA organizational structure and make the
necessary changes to implement quality controls and ensure
compliance with directives.
Comments
The Acting Under Secretary for Health
concurred with the findings and recommendations. See Appendix D
(pages 41–43) for the full text of his comments. He stated his
commitment to resolve the urgent management and clinical issues
involved. VHA will provide its detailed plan of corrective action
in July 2009.
We will follow up on the corrective actions until all
recommendations have been fully implemented.
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TOPICS:
veterans, veterans' benefits, VA, Department of Veterans' Affairs,
contaminated equipment, endoscopic, hepatitis B, hepatitis C, HIV
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