Late Breaking News
More Potential Infections at Miami VAMC
- Categorized in: June 2009 Issue
Washington—Another Department of Veterans Affairs facility has announced in April that it may have exposed patients to infection during the course of routine colonoscopies. The Miami VAMC stated that as many as 3,000 veterans who underwent colonoscopy between May 2004 and March 12, 2009 may have been put at risk of HIV and hepatitis infection due to improperly sterilized equipment. This announcement came after a self-evaluation performed by the hospital in January reported no problems. Legislators are calling for a VA Inspector General investigation into the incident at the Miami hospital.
Miami VAMC patients were notiﬁed of the problem last month. The hospital set up a call center so that veterans can speak with healthcare staff about the issue and offered immediate free blood test screening, or the option that the veteran can see a provider.
This latest incident follows two similar ones that were discovered in December at VA hospitals in Murfreesboro, Tenn. and Augusta, Ga. At those facilities a combined 8,000 patients may have been exposed during colonoscopies and endoscopic procedures due to inadequate cleaning of medical equipment. VA leaders ordered hospitals evaluate their cleaning procedures and called for a “Step-Up” from March 8 to 14 where every VA hospital and clinic would participate in a special training campaign on safety.
The Miami VAMC evaluated their colonoscopy cleaning procedures in January and on January 7 ﬁled a report giving the hospital a clean bill of health. However, during a more intensive review two months later, the hospital discovered that the tubing attached to the colonoscopy equipment was apparently not serviced according to manufacturer’s guidelines. This created the possibility that organic material, including infected material, could travel from the tube to the patient.
Rep. Kendrick Meek, D-Fla., requested an ofﬁcial inquiry into the incident by George Opfer, Inspector General of the VA. “Given the awful circumstances, the Miami VA Healthcare system has acted expeditiously to notify veterans of this personal health and public health danger,” Rep. Meek said in a letter to VA Secretary Eric Shinseki. “Needless to say, hepatitis B, hepatitis C, and HIV are communicable and what may affect as many as 3,260 individuals could quickly expand to include a much larger pool of people. While we can never adequately pay back our veterans for their service to our country and dedication to the uniform they wore, we can try to assist by providing them with the top level of medical care they deserve. The VA is a model of the type of healthcare we provide our veterans and when mistakes like this occur, it undermines the efﬁcacy of the entire system.”
Rep. Steve Buyer, R-Ind., ranking Republican on the House VA Committee, asked for an immediate brieﬁng by VA ofﬁcials on the incident and echoed Rep. Meek’s call for an IG investigation. “It is inconceivable that the incident in Miami occurred after VA directed multiple system-wide reviews of all endoscopic procedures,” said Rep. Buyer. “After the Miami center staff did a self-assessment and gave itself a clean bill of health, I expect the Department to determine who was responsible for these gross medical errors and hold those individuals accountable.”