Among the 129 facilities inspected in August, all 129 were compliant with respect to SOPs.

by Larry Scott, VA Watchdog dot Org

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The VA's Office of Inspector General (VAOIG) has issued their follow-up report on the contaminated equipment issue at three VA facilities.

All information on this VA fiasco is on our Contaminated Equipment page ... here ...
http://www.vawatchdog.org/conta
minatedequipment.htm

At this time, 57 veterans have tested positive for HIV, hepatitis B or hepatitis C after getting an endoscopic procedure at one of three VA facilities.

VAOIG's original report take the VA to task for improper sterilization procedures.  That report is here ...

Healthcare Inspection Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities -- Report Number 09-01784-146, 6/16/2009 | Summary | Report (PDF)

And, two articles about the original report can be found here ...

VAOIG FINDS FUNDAMENTAL DEFECTS IN VA HEALTH CARE (06-16-09)   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.

VAOIG: VA'S CONTAMINATED EQUIPMENT COULD BE WIDESPREAD (06-16-09)   Leaked VAOIG report states only 43% of VA facilities had proper training and guidelines in place for endoscopic procedures.

Now, VAOIG has taken a second look to see if VA facilities are following the rules when it comes to sterilizing endoscopic equipment.

That new report is here ...

Healthcare Inspection Follow-Up Colonoscope Reprocessing at VA Medical Facilities -- Report Number 09-02848-218, 9/17/2009 | Summary | Report (PDF)

All-in-all, it's not a bad report.  Perhaps, a little late, some lessons have been learned.

Report Summary is below:

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Executive Summary

The Secretary of Veterans Affairs requested that the VA Office of Inspector General (OIG) conduct an inspection of endoscopy reprocessing at Veterans Health Administration (VHA) facilities in follow-up of OIG’s initial report, Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities, Report No. 09-01784-146, published June 16, 2009.

Several VHA medical facilities had been found to deviate from recommended procedures in the reprocessing of endoscopes, in some cases necessitating patient recalls. The June report described those incidents, VHA’s responses to them, and results from an unannounced OIG inspection of a sample of facilities in May 2009. In May we conducted unannounced inspections at 42 facilities. Colonoscopes were reprocessed in 38 reprocessing units at 36 of these facilities. We found that 42.5 per cent of reprocessing units had adequate standard operating procedures (SOPs) and documentation of demonstrated competence for reprocessing staff
This current follow-up inspection provides results for all facilities not previously inspected and provides follow-up results for facilities previously found to be not compliant with VHA Directive 2009-004, Use and Reprocessing of Reusable Medical Equipment (RME) in Veterans Health Administration Facilities, issued February 9, 2009.

This inspection was limited to colonoscope reprocessing. For facilities not previously inspected, inspections involved all reprocessing locations at each facility. For facilities previously inspected, this follow-up inspection addressed only reprocessing locations previously found to be not fully compliant at the initial inspection in May. VHA was informed that this inspection would occur and the criteria to be used, but visits to all facilities were unannounced and unscheduled.

Among the 129 facilities inspected in August, all 129 were compliant with respect to SOPs; 128 facilities had adequate documentation of demonstrated competence for reprocessing staff.

In our initial report, we recommended that the Acting Under Secretary for Health ensure compliance with relevant directives regarding endoscope reprocessing, explore possibilities for improving the reliability of endoscope reprocessing with VA and non-VA experts, and review the VHA organizational structure and make the necessary changes to implement quality controls and ensure compliance with directives. The Acting Under Secretary for Health concurred with the recommendations and provided a plan of corrective action. OIG will follow up on actions until all recommendations have been fully implemented.

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