New Report of Ignored Warning Surfaces as VA Facilities Wrestle with Sterilization Breaches


Even as investigation into sterilization protocol breaches continues at the John Cochran VA Medical Center in St. Louis, The Augusta Chronicle is reporting that an infection preventionist's warnings about problems related to the disinfection and sterilization of reusable flexible endoscopes at the Charlie Norwood VA Medical Center in Augusta, Ga. were discounted. According to the article, "in late 2008, the VA notified more than 10,000 veterans that they might have been exposed to improperly cleaned equipment, and it offered testing. More than 50 cases of infection, from hepatitis C to HIV, have since been found, though VA officials say it is unlikely the scopes caused the infections."

Writer Tom Corwin reports that in April 2008, an Augusta VA employee raised the alarm about the sterilization of flexible endoscopes, and writes, "Infection control practitioner David Marana had attended a conference for VA infection control workers in April 2008. Shortly after returning, Marana sent out an e-mail saying the VA was not following standards he had learned about at the conference." According to Corwin, Marana wrote in the e-mail, "At this time, I recommend that services involving reusable flexible scopes be discontinued until we have met the standards." Corwin says that "Marana, who is no longer with the VA and was reluctant to talk to The Chronicle, did say he thought some of the problems discovered later could have been headed off 'if people had listened to me and took the recommendations seriously.'" Corwin reports further, "The minutes from the infection control meeting, called soon after Marana's e-mail, stated that endoscope cleaning in "several areas of the hospital ... are not in compliance with standards set forth" in VA Directive 7176. Ellen Harbeson, the Augusta VA's quality management coordinator, said the conference that Marana attended provided misinformation about Directive 7176, particularly which VA department was supposed to oversee the department where the reprocessing is done."

To read from the the article in The Augusta Chronicle, CLICK HERE.

St. Louis Public Radio is reporting that late last week, Missouri Sen. Claire McCaskill met with senior staff at John Cochran VA Medical Center and that she feels "reassured that the faulty sterilizations at the hospital's dental clinic discovered earlier this year have been addressed." More than 1,800 veterans may have been exposed to bloodborne diseases such as hepatitis B and C or HIV due to improperly disinfected and sterilized instruments.

In mid-July, in submitted written testimony to the the U.S. House Committee on Veterans' Affairs. McCaskill notes, "We all agree that veterans receiving treatment 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. This one incident is disturbing enough, but unfortunately John Cochran VAMC has been the source of other violations and low customer service ratings in the past. In April 2010, the VA Inspector General released a report outlining reprocessing problems with endoscopes used at John Cochran VAMC. Prior to that, John Cochran received some of the lowest customer service satisfaction ratings of any VAMC in the country. I know that efforts have been made to address these problems by the VA, but the latest revelations about the improper dental device sterilization pose a significant setback to progress. I am also deeply concerned that the VA took four months (from March until the end of June 2010) to notify veterans who may have been endangered by the flawed procedures at John Cochran VAMC, as well as to notify the area Congressional delegation so that we might assist our constituents, many of whom have called my office worried and outraged about this incident. I 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 VAMC by VA headquarters staff was not conducted until May 2010, some two months after the initial inspection revealed problems with the cleaning of the dental devices. When a significant failure in procedures occurs, like those discovered at the John Cochran VAMC dental clinic, I would expect a more timely response and more aggressive oversight. There must be an evident and palpable sense of urgency from the VA. It is clear the VA now has such a sense of urgency and it must continue."

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