By JIM SALTER (AP) – 12 minutes ago
ST. LOUIS — The Veterans Administration said Thursday that the chief of dental services at a St. Louis VA Medical Center has been placed on administrative after the hospital urged nearly 2,000 veterans to return for blood tests because inadequately sterilized equipment may have exposed them to viral infections during dental procedures.
An independent board will also investigate how employees failed to properly sterilize the dental equipment that potentially exposed veterans to infections including hepatitis and HIV, the administration said.
"The mistakes made at the St. Louis VA Medical Center are unacceptable, and steps have been and continue to be taken to correct this situation and assure the safety of our veterans," VA Secretary Eric Shinseki said.
The VA sent letters out Monday to 1,812 veterans who had dental procedures at the St. Louis center from Feb. 1, 2009, through March 11 of this year, saying reviews determined that some sterilization steps in preparing dental instruments were not in compliance with standards.
Officials say the infection risk is extremely low, and no illnesses have been uncovered so far out of some 100 veterans who have come in for blood work that will screen for hepatitis B, hepatitis C and HIV.
Rep. Russ Carnahan, D-Mo., said the House Veterans' Affairs Committee also said they will investigate what happened at the center and planned to hold a hearing in St. Louis. The announced investigations follow demands for action by several lawmakers from Missouri and Illinois — the St. Louis region's five VA facilities serve veterans in both states.
VA Under Secretary for Health Dr. Robert Petzel said he found there was a need for an independent review by the national Administrative Investigation Board "to determine the reasons for failure to follow correct procedures."
No date has been set for the Veterans' Affairs Committee hearing in St. Louis. Two Missouri congressmen, Republican Blaine Luetkemeyer and Democrat William Lacy Clay, also asked the House Oversight and Government Reform Committee to investigate. Both serve on that committee.
Lawmakers also want to know why it took so long for the VA to inform the veterans about the mistakes. The problem was uncovered in March and letters went out Monday.
Marcena Gunter, a spokeswoman for the St. Louis center, said the delay was because officials were evaluating the risk posed to veterans.
The name of the suspended chief of dental services was not released. A VA spokeswoman did not respond to interview requests.
The VA said patients who have had dental procedures since March 11 are not at risk because procedures were corrected.
Shinseki said that over the past 18 months, VA has implemented more stringent safety oversight at its medical facilities, and that oversight led to the identification of problems at the St. Louis facility.
VA centers around the country have had problems in recent years. In 2007, Walter Reed Army Medical Center in Washington came under scrutiny over concerns about conditions at the hospital and treatment of veterans. At the time, St. Louis VA officials said they were working to fix similar problems.
That same year, a surgeon at the VA hospital in Marion, Ill., resigned after a patient bled to death following gall bladder surgery. All inpatient surgeries were suspended. The VA found at least nine deaths between October 2006 and March 2007 resulted from substandard care at the Marion hospital, and another 10 patients died after receiving questionable care that complicated their health.
Copyright © 2010 The Associated Press. All rights reserved.
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Text of the senators' letter
Wednesday, Jun. 30, 2010
General Eric Shinseki Secretary of Veterans Affairs
Department of Veterans Affairs
810 Vermont Avenue, Northwest
Washington, DC 20420
Dear Secretary Shinseki: Please note our deep disappointment and concern that 1,812 St. Louis area veterans were potentially exposed between February 2009 and March 2010 to dangerous blood-borne diseases, including Hepatitis B and C and HIV, through possible contact with improperly cleaned dental devices at the John Cochran VA Medical Center (VAMC) in St. Louis, Missouri. In light of other recent revelations by the VA Inspector General regarding problems with reprocessing of endoscopes at John Cochran and frequent customer service satisfaction problems reported at John Cochran, we are concerned about VA management of the facility. Veterans receiving care at John Cochran deserve the best quality care available, including absolute assuredness that the hospital is meeting the most basic and critical professional standards of cleanliness and conduct. We are also deeply concerned that the VA took four months to notify veterans who may have been endangered by the flawed procedures at the John Cochran VAMC, as well as to notify the area Congressional delegation so that we might assist our constituents. We appreciate that the VA acted quickly to remedy the flawed cleaning procedures but the failure to share information in a timely fashion about the situation is unacceptable. In addition, a follow up visit to John Cochran by VA Headquarters staff was not conducted until May, some two months after the initial inspection revealed problems with the cleaning of the dental devices. When a significant failure in procedures occurs, like that discovered at the John Cochran VAMC dental clinic, we would expect a more timely response and more aggressive oversight. The VA has decided to dedicate $5 million in funding to make infrastructure and other improvements at the John Cochran VAMC in light of this troubling incident. While we applaud the VA’s efforts to address aggressively underlying problems, including infrastructure problems that could have contributed to the failures in the dental clinic, we must be kept apprised of how the $5 million in renovations will be spent and prioritized. Please keep us informed about any follow up actions that the VA takes to train staff and improve standard operating procedures in the dental clinic and elsewhere in the hospital.
In closing, as you evaluate each of the 1,812 veterans who have received letters from the VA about potential exposure from improperly handled dental devices, we ask for an accounting of any health irregularities identified and attributed to the exposure. We know you value the health and safety of each and every veteran and strongly urge you to make sure that no veteran’s health goes unchecked in this case. We are committed to working with you, Mr. Secretary, to provide veterans with the resources they need to heal—resources they earned through their great service. The repeated failures to follow simple rules and regulations, however, is wholly unacceptable, and we want to know the measures you plan to implement in order to ensure this catastrophe never happens again. We thank you for your immediate attention to this matter and look forward to your reply. Should you have additional questions please feel free to contact us directly or to have your staff contact Tressa Guenov in Senator McCaskill’s office, Bo Prosch in Senator Bond’s office or Gabe Chavez in Senator Durbin’s office.
Sincerely,
Claire McCaskill UNITED STATES SENATOR
Christopher Bond UNITED STATES SENATOR
Richard Durbin UNITES STATES SENATOR
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See Also:
Military men and women suffer abuse at the hands of their own doctors
VA hospital may have infected 1,800 veterans with HIV
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