VA's assistant inspector general, John Daigh, who led the review of VA's contamination problem, said the findings in the VAOIG report "troubled me greatly." He went on to state: "We think there are systemic issues,".
The VAOIG Report found that fewer than half of VA facilities selected for surprise inspections last month, by the VAOIG, had proper training and guidelines in place, even though it had been months since VA had launched a nationwide safety campaign following the discovery of failures to properly sterilize equipment [errors] at VA facilities in Miami, Augusta, Ga., and Murfreesboro, Tenn.
One of the new details that came to light is that workers at Miami's center "didn't know for almost five years that they should have been sterilizing an irrigation part on an endoscope used for routine colonoscopies. They also weren't cleaning a water tube between each procedure as recommended by the manufacturer and were mistakenly attaching the water system to the scope during the colonoscopy instead of before, possibly allowing contamination of sterile components."
How many other breaches of basic medical protocol and procedures are occurring in VA medical facilities?
When James Bagian, VA's chief patient safety officer, was asked about the mistakes, his response was "You don't know you're wrong until you know you're wrong,"
Well I suggest that you get someone in there that knows when things are wrong and have them review everything every procedure in every VA medical Center because veterans deserve to know that everything is done correctly, that anything being done wrong is corrected, YESTERDAY.
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