By Patricia Kime - Staff writer
Posted : Thursday Jan 19, 2012 17:57:33 EST
The top Democrats on the House and Senate Veterans’ Affairs committees are seeking an investigation of the Veterans Affairs Department’s handling of several incidents involving improper sterilization of reusable medical equipment.
The lawmakers say those problems could be an indication that VA leaders are not following their own guidelines for investigating such incidents or disciplining those responsible.
In a Jan. 19 letter to Government Accountability Office Comptroller Gene Dodaro, Sen. Patty Murray, D-Wash., and Rep. Bob Filner, D-Calif., asked for a GAO review of VA’s procedures and policies.
“We continue to hear about the same types of quality-of-care incidents at VA medical facilities and we are concerned this is an indication that VA is not effectively learning from these incidents and subsequently translating these lessons into system-wide improvements,” Murray and Filner wrote.
In the past seven years, more than 13,000 veterans treated at VA health facilities have been placed at risk for exposure to infectious disease such as hepatitis and HIV after undergoing procedures with improperly sterilized equipment.
From 2004 to 2009, 11,000 veterans at the Murfreesboro, Tenn., Augusta, Ga., and Miami VA medical centers were notified of their risk after they underwent colonoscopies with improperly prepared endoscopes.
At least 25 veterans contracted Hepatitis C, eight developed Hepatitis B and five tested positive for HIV.
In January 2011, surgeries at the St. Louis VA Medical Center were halted after VA found 1,812 vets were placed at risk from improperly sterilized surgical equipment.
And in Dayton, Ohio, VA offered to test 500 veterans for possible exposure after leaders determined a dentist didn’t change his latex gloves between patients.
“On numerous occasions, VA has reported to Congress about the various investigations it has conducted and the problems these investigations have identified, which they claim to have led to the development of new processes and procedures to reduce risk,” the lawmakers wrote.
In October, members of the House Veterans’ Affairs Committee were surprised to learn that Miami VA Medical Center Chief Mary Berrocal still had her job.
Berrocal received a letter of admonition in 2009 after the colonoscopy scandal surfaced but remained as chief until November, roughly a month after she testified that conditions at the facility were improving.
Her testimony came a week after a Miami VA employee was arrested for selling the names and personal information of 18 patients and compromising the personal data of 3,000 veterans, and three months after a veteran was allowed to leave the medical center when she should have been placed on suicide watch.
Veteran Catawba Howard was shot by police just hours after she left the medical center.
“This raises concerns as to whether VA’s leadership is taking appropriate actions, including appropriate disciplinary actions, to effectively address the problems across the system,” the lawmakers wrote.
VA spokesman Josh Taylor said Thursday that the department is committed to providing safe, high-quality care.
He said VA agrees with Murray and Filner that “every health care provider must ensure they follow good infection-control practices and that they send equipment for proper reprocessing. Failure to do so is unacceptable.”
Taylor added that VA has been recognized by the New England Journal of Medicine for its patient disclosure policy, what he called a “reflection of VA’s commitment to transparency.”
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