Friday, April 17, 2009

Timeline: VA Endoscopy Alerts and Notices

Time Line for VA Alerts regarding endoscopes and processing

VHA Patient Safety Alerts and Advisories
http://www.va.gov/ncps/alerts.html

Note: This list of alerts is not complete.
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March 8, 2002 Alert
Bronchoscopes Manufactured by Olympus America
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March 6, 2003 Advisory
Olympus EXERA™ Gastrointestinal Endoscopes
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February 13, 2004 Alert
Connectors for Sterilization of all Gastrointestinal Fiberoptic Endoscopes
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October 5, 2005 Alert
Olympus 180 series endoscopes and Steris Quick Connects
PDF Version | Word Version
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March 12, 2008 Alert
STERIS C1160 Universal Flexible Processing Trays used with the STERIS System 1 Sterile Processing Systems
AL08-11
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March 31, 2008 Alert
Improper reprocessing of flexible endoscope biopsy valves
AL08-13
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December 22, 2008 Alert
Improper set-up and reprocessing of flexible endoscope tubing and accessories
AL09-07
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Miami Herald 2009 Time line
http://www.miamiherald.com/news/more-info/story/1005226.html

• January: VA facilities and hospitals review processes and report back to Washington. The Miami VA reports that it has no sanitization problems.

• Feb. 10: The VA center in Augusta, Ga., sends letters to 1,100 veterans who had endoscopic procedures at its ear, nose and throat clinic, warning they might have been exposed to hepatitis B, hepatitis C or HIV. It said that between January and November 2008 the equipment might not have been properly sanitized.

• Feb. 13: The VA medical center in Murfreesboro, Tenn., sends letters to nearly 6,400 veterans warning that improperly assembled colonoscopy equipment may have exposed them to hepatitis B, hepatitis C and HIV. The problem occurred between April 23, 2003 and Dec. 1, 2008, it said.

• March 8-14: The VA initiates a ''step-up'' program directing all VA hospitals and clinics to check if they have contamination problems, and to set up new training programs. In the course of the new inspection, the Miami VA discovers its problem and reports it to Washington.

• March 23: The Miami VA medical center sends a letter to about 3,260 veterans, warning that if they had colonoscopies at the local hospital, improperly sanitized equipment might have exposed them to hepatitis B, hepatitis C or HIV.

• March 27: A five-member team from the VA arrives in Miami to investigate what went wrong. Members of Congress call for additional probes by the VA Inspector General's Office and the U.S. House Committee on Veterans' Affairs.

• April 17: The VA announces that one Miami veteran has tested positive for HIV, seven for hepatitis C and none for hepatitis B.

Update: Contaminated endoscopes: VA can't say that any VA facility properly sterilized their endoscopy equipment.

Given VA statement that "it does not yet know if veterans treated with the same kind of equipment at its other 150 hospitals may have been exposed to the same mistake before the department had a nationwide safety training campaign.

Given this uncertainty and the deadly nature that such an exposure can have, it is time for the VA to step forward and have everyone tested. This means each and every veteran, at each of the 150 VA medical facilities, that may of been exposed.

We urge every veteran that has undergone any type of "endoscopy" procedure at any VA facility to get tested. Request a copy of all your medical records, TODAY.

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Initial tests show one patient each from VA medical facilities in Murfreesboro, Tenn.; Augusta, Ga.; and Miami has the virus that causes AIDS, according to a VA statement.
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The VA also said there have been six positive tests for the hepatitis B virus and 19 positive tests for hepatitis C at the three locations.

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http://news.yahoo.com/s/ap/20090417/ap_on_re_us/veterans_colonoscopies;_ylt=AhzhBJRiINXNvE6t.a3i3O.s0NUE;_ylu=X3oDMTFlZ211NGk5BHBvcwM1OARzZWMDYWNjb3JkaW9uX3Vfc19uZXdzBHNsawN2YTNwYXRpZW50c2g-

VA: 3 patients HIV-positive after clinic mistakes

By BILL POOVEY, Associated Press Writer Bill Poovey, Associated Press Writer – 36 mins ago

CHATTANOOGA, Tenn. – Three patients exposed to contaminated medical equipment at Veterans Affairs hospitals have tested positive for HIV, the agency said Friday. Initial tests show one patient each from VA medical facilities in Murfreesboro, Tenn.; Augusta, Ga.; and Miami has the virus that causes AIDS, according to a VA statement.

The three cases included one positive HIV test reported earlier this month, but the VA didn't identify the facility involved at the time.

The patients are among more than 10,000 getting tested because they were treated with endoscopic equipment that wasn't properly sterilized and exposed them to other people's body fluids.

Vietnam veteran Samuel Mendes, 60, said he was surprised to learn of an HIV case linked to the Miami facility, where he had a colonoscopy. He was told he wasn't among those at risk.

"I was hoping and expecting to not get anyone contaminated like that," he said. "It's probably a little worse than we thought."

The VA also said there have been six positive tests for the hepatitis B virus and 19 positive tests for hepatitis C at the three locations.

There's no way to prove patients were exposed to the viruses at its facilities, the agency said.

"These are not necessarily linked to any endoscopy issues and the evaluation continues," the statement said.

The VA has said it does not yet know if veterans treated with the same kind of equipment at its other 150 hospitals may have been exposed to the same mistake before the department had a nationwide safety training campaign.

An agency spokeswoman has said the mistake with the equipment was corrected nationwide by the time the campaign ended March 14. The problems discovered in December date back more than five years at the Murfreesboro and Miami hospitals.

The VA's disclosure Friday was the department's first comment since April 3, when the VA reported the one positive HIV test.

VA spokeswoman Katie Roberts has declined to provide any details on how widespread the problems might have been other than saying a review of the situation continues.

She said in an e-mail Friday that "there is a very small risk of harm to patients from the procedures at each site." She said the HIV results "still need to be verified" in additional tests.

The VA statement shows the number of "potentially affected" patients totals 10,797, including 6,387 who had colonoscopies at Murfreesboro, 3,341 who had colonoscopies at Miami and 1,069 who were treated at the ear, nose and throat clinic at Augusta.

More than 5,400 patients, about half of those at risk, have been notified of their follow-up test results, the VA said.

The Friday statement said the VA is "continuing to notify individuals whose letters have been returned as undeliverable, and working with homeless coordinators to reach veterans with no known home address."

The statement also said the VA has assigned more than 100 employees at the three locations to "ensure that affected veterans receive prompt testing and appropriate counseling."

All three sites used endoscopic equipment made by Olympus American Inc., which has said in a statement it is helping the VA address problems with "inadvertently neglecting to appropriately reprocess a specific auxiliary water tube."

Charles Rollins, 62, who served three tours in Vietnam with the Navy from 1966 to 1969, said the news concerns him because he's used the Augusta ear, nose and throat clinic several times.

"That's terrible," he said by phone as he socialized at an American Legion post in Augusta.

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Associated Press writers Lisa Orkin in Miami and Dorie Turner in Atlanta contributed to this report.