The "variance" in procedure, as the hospital's chief of staff, Dr. Luke "Mike" Stapleton, termed it, did not put any patients at risk of infection because it was simply a label that was put on a tray "out of sequence."
"That doesn't mean it got poorly sterilized; it doesn't mean it's a bad product," he said. "It just shows that there was a variance from our normal protocol."
The glitch occurred Nov. 16 and was discovered during a routine review that same day. All elective surgeries were suspended as a precaution Nov. 17. Some will be restored by Tuesday, but Stapleton could not say when all elective surgeries will be performed again.
"I do anticipate this to be in the timeframe of a week or two, not a month or two," he said.
He emphasized that all emergency and urgent surgical procedures are still going forward, and that he and the medical staff are confident that the equipment used in those procedures is safe for patients.
Stapleton said that during each operation, a surgical tray is prepared with the equipment needed for that particular procedure.
After the operation is finished, a decontamination process takes place involving washing, scrubbing and sending reusable equipment through a sterilizer before it is labeled.
On Nov. 16, the label was placed on the tray before the sterilization process had been completed, though the review showed that the equipment did get sterilized, Stapleton said.
The chief of staff said that, out of an abundance of caution, medical center staffers decided to resterilize all reusable medical instruments.
"Because we're the VA, and the things we do are in a fishbowl, and because we've had patients we've notified over this past week that we are postponing their surgery to a later date, we decided we wanted to inform the public," Stapleton said.
He acknowledged that a highly publicized incident from 2008 in which thousands of patients were potentially exposed to infection because of a problem with sterilization of equipment also contributed to the hospital staff's decision to resterilize.
"From past history here, as well as within the VA system as a whole, we've all learned our lessons over time," Stapleton said. "Anything that deals with the (supply, processing and distribution) process, we really do take the high ground."
In September, The Augusta Chronicle reported that an Augusta VA employee sent out an e-mail in April 2008 -- several months before others noticed -- raising alarm about the sterilization of flexible endoscopes.
In November 2008, after a Norwood patient noticed a problem, the VA notified more than 10,000 veterans that they might have been exposed to improperly cleansed 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's unlikely they came from the equipment, The Chronicle reported.