VA Botches Spelunking for Turds

WASHINGTON (AP) — Lawmakers sharply criticized the Department of Veterans Affairs on Tuesday about why a national scare over botched colonoscopies earlier this year didn't prompt stronger safeguards at the agency's medical centers.

Agency officials apologized for the continued weaknesses and told a House subcommittee that they would do better. House Veterans Affairs Committee Chairman Bob Filner, D-Calif., said VA Secretary Eric Shinseki has pledged to take disciplinary action.

The strong reaction came as the agency's inspector general reported that fewer than half of VA facilities selected for surprise inspections last month had proper training and guidelines in place. That was months after the VA launched a nationwide safety campaign over the discovery of errors at facilities in Georgia, Florida and Tennessee that could have exposed veterans to HIV and other infections.

John Daigh, VA's assistant inspector general who led the review, said the findings "troubled me greatly."

"We think there are systemic issues," Daigh said.

Lawmakers expressed disbelief that medical centers wouldn't have immediately tightened procedures after the safety alert.

"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 Filner, who praised the VA for being transparent about the mistakes. "There will be a public accounting of this situation."

The VA in February began warning about 10,000 former patients in Georgia, Tennessee and Florida — some who had colonoscopies and other endoscopic procedures as far back as 2003 — that they may have been exposed to infections and to get blood tests for HIV and hepatitis.
The agency says that six veterans who took 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.

The VA has said — through self-reporting from all of its facilities — that such errors were limited to the centers in Murfreesboro, Tenn., Augusta, Ga., and Miami. But the inspector general report suggests problems could be more widespread because hospitals are using different equipment with varying degrees of training and standardized cleaning procedures.

In the surprise inspections, conducted May 13-14 at 42 VA medical centers, investigators found that only 43 percent had standard operating procedures in place and could show they properly trained their staffs for using their equipment. VA officials struggled to explain the findings and said it would overhaul its procedures for colonoscopies and other common endoscopic procedures.

"The (VA) has decided that what we've been doing, business as usual, is not satisfactory," said William Duncan, an associate deputy undersecretary for quality and safety. "We were extremely disappointed with the findings of the inspector general's report and we regret that we were not 100 percent in compliance." The VA says the problems were caused by human error in the cleaning and operation of endoscopic equipment.

At the Murfreesboro facility, for example, officials believe medical staff mistakenly used a two-way valve that may have allowed bodily fluids to enter a part of the scope that was believed to be sterile.

Several top VA officials with experience at private hospitals said similar discoveries in the private sector would not have been publicized without specific knowledge that a patient was harmed.

Daigh said his investigators tried unsuccessfully to get information about potential problems at private hospitals, and several lawmakers said they think the problem probably extends beyond the VA.

"If this is happening in VA, what is happening ... in our greater health system?" said Rep. Steve Buyer of Indiana, the top Republican on the committee. "My sense is that there are some greater problems out there."