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Last week, the U.S. Office of Special Counsel (OSC) transmitted to the President and Congressional oversight committees findings of a Department of Veterans Affairs (VA) investigation confirming that improperly cleaned and poorly sanitized instruments were distributed to clinics and operating rooms at the VAs G.V. Montgomery Medical Center (Jackson VAMC) in Jackson, Miss.
OSC received these allegations from a whistleblower and referred them to the Secretary of the VA for further investigation. The report of that investigation, which was conducted by the Veterans Health Administration (VHA), confirmed that dirty and rust-stained instruments, such as scalpels, blade handles, tissue and nail nippers, hemostats, and bone cutters, were issued for use within the Jackson VAMC. The report noted that generally, on occasions when dirty instruments were distributed, staff discovered them prior to use and replaced them with clean instruments. The report also stated that prior to 2006, providers specifically in the Jackson VAMC podiatry clinic experienced frequent instrument shortages, resulting in the reuse of unsterilized instruments. The agency stated that this problem was resolved by the purchase of additional instruments.
In response to the sterilization problems that the investigation identified within the podiatry clinic, the agency convened a Pre-Clinical Risk Assessment Board (Pre-CRAAB) to determine whether the possible exposure to veterans prior to 2006 required that notice be given regarding possible infection. The Pre-CRAAB was comprised of VA staff from VA headquarters in Washington, D.C. and local staff from the Jackson VAMC. The Pre-CRAAB determined that the risk to patients was negligible and that notice was not required.
In response to these allegations, the agency pledged to follow up with the Jackson VAMC to ensure full compliance with proper cleaning and sterilization processes hospital-wide. The Jackson VAMC also committed to paying close attention to equipment issues within the podiatry clinic, and to purchasing a new type of instrument and evaluating the chemicals in the instrument washer to ensure cleanliness. A podiatrist was added to both leadership rounds and the Reusable Medical Equipment (RME) Oversight Committee and a quality manager was hired for RME. In addition, the Jackson VAMC began the hiring process to fill the positions of chief and assistant chief of supply, processing, and distribution (SPD) section, the section responsible for cleaning and sanitizing instruments, as well as six full-time equivalent SPD support positions. The hospital also pledged to assess the learning needs of current SPD staff and to provide them with training and assistance in achieving certification. OSC determined that the agencys report contains all the information required by statute and the agencys findings appear reasonable. However, OSC noted with concern the whistleblowers comments that the Jackson VAMC continues to distribute instruments which have not been properly cleaned and sterilized. OSC also expressed its concern that the Pre-CRAAB process, as described by the agency, could be compromised by the involvement of management officials who are potentially directly responsible for allowing the underlying conduct to continue.