VA Inspections Show Continued Flaws

A report by the Veterans' Administration's inspector general finds less than half of the VA facilities given a surprise inspection last month had appropriate training and guidelines in place for common endoscopic procedures, suggesting the recently disclosed errors that potentially exposed thousands of veterans to HIV and hepatitis may be more widespread than initially thought.

The House Veterans Affairs subcommittee will take up the report in a hearing with VA officials today. Rep. Harry Mitchell (D-Ariz.), who will chair the hearing, said Monday the findings are a "damaging blow to the trust veterans place in the VA."

The random visits were conducted May 13-14 at 42 VA sites across the country. Inspectors found that just 43 percent of the medical centers have standard operating procedures in place and have properly trained their staff on endoscopic equipment use.

The inspector general's investigation follows the discovery of improper handling of endoscopy equipment at the VA hospital in Murfreesboro, Tenn., which led to a nationwide safety campaign at all of the agency's 153 medical centers. Mistakes were also identified at facilities in Miami and Augusta, Ga., prompting the notification that about 10,000 former patients at the three sites should get blood tests for HIV and hepatitis.

In Murfreesboro, officials believe the use of a wrong valve may have allowed body fluid residue to transfer from patient to patient, stemming back to 2003. In Miami, a tube that should have been cleaned after each colonoscopy was instead cleaned at the end of the day, affecting patients between May 2004 and March 2009. In Augusta, ear nose and throat scopes were improperly sterilized from January to November 2008.

In a statement, VA spokesperson Katie Roberts said the agency is taking aggressive action to ensure that each facility is in compliance with correct standard operating procedures.

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