June 25, 2009
On Wednesday at a hearing called in response to revelations of poor infection-control practices at three VA medical facilities, the chair of the Senate Veterans Affairs Committee said the VA's medical system needs more centralized control. "True quality assurance has to be managed across the system and that means central office must exercise greater control," said Sen. Daniel Akaka (D-Hawaii).
Since February, when the VA began warning some 10,000 patients of its facilities in Miami, Murfreesboro, Tenn., and Augusta, Ga., of a years-long pattern of errors in disinfecting endoscopy equipment, six patients have tested positive for HIV, 34 for hepatitis C, and 13 for hepatitis B. It is not possible to trace the infections directly to the flawed cleaning practices.
"The more I learn about this case, the more it seems to be a case of extreme negligence," said Sen. Richard Burr (N.C.), the committee's ranking Republican. "With multiple past incidents, multiple warning signs, there is no possible justification as to why this has still not been corrected."
Burr and other senators questioned whether the VA's Ann Arbor, Mich.-based national center overseeing patient safety is high enough on its organizational chart.
While the VA has maintained that the errors were limited to the sites implicated in the current investigation, the agency's inspector general last week released a report suggesting the problems are more widespread. The VA said a "small low-risk event" at its Mountain Home, Tenn., facility "has revealed no positive tests."
The VA is releasing $26 million from reserve funds to buy new equipment to improve the cleaning of endoscopes and other reusable medical devices, said Katie Roberts, an agency spokesperson.