Tuesday, June 16, 2009

Congressional Inquiry Provides No Real Assurance to Veterans

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.


Full article:
AP Article

VAOIG Report, VA Not in Compliance with Management Directives for Reprocessing of Endoscopes

Just posted VAOIG report concludes that their "extensive review concluded that facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans."


Report Summary

Healthcare Inspection Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities

Report Number 09-01784-146, 6/16/2009

Full Report (PDF)
http://www.va.gov/oig/54/reports/VAOIG-09-01784-146.pdf

The Secretary and VA’s Congressional oversight committees requested a review of the reprocessing of endoscopic equipment at several specific VA medical centers (VAMCs), and an assessment of the extent of related problems throughout the Veterans Health Administration (VHA).

Our extensive review concluded that facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans. Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care. The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure. Nevertheless, we did conclude that the Clinical Risk Assessment Advisory Board has been an effective mechanism for providing guidance to VHA leadership on disclosure of adverse events to veterans. We recommended that VHA management ensure compliance with relevant directives regarding endoscope reprocessing, explore possibilities for improving the reliability of endoscope reprocessing with VA and non-VA experts, and review the VHA organizational structure and make necessary changes to implement quality controls and ensure compliance with directives.