Warning of VA patients' risk was discounted

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Nearly seven months before a patient at Charlie Norwood VA Medical Center noticed a problem with sterilizing equipment, setting off a national investigation that found thousands of patients potentially exposed to infection, an employee pointed out problems with sterilization of that equipment.

Augusta VA officials insist the employee was relying on misinformation that would not have caught or corrected the problem.

After the patient's discovery in November 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's unlikely they came from the equipment.

Seven months before others noticed, in April 2008, an Augusta VA employee sent out an e-mail raising alarm about the sterilization of flexible endoscopes, according to information obtained by The Augusta Chronicle .

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.

"At this time, I recommend that services involving reusable flexible scopes be discontinued until we have met the standards," he wrote.

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."

Catherine McAdams, a nurse in infection control, also attended the conference.

"They were told, 'Stop. Don't do it any more,' " said McAdams, who also has left the VA. "You're not doing it right. You're not doing it correctly. People are going to get hurt.' "

VA cites misinformation

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 and McAdams attended provided misinformation about Directive 7176, particularly which VA department was supposed to oversee the department where the reprocessing is done.

Though speakers at the conference asserted that infection control was supposed to oversee that department, "that is completely false," Harbeson said. Supervision was later changed after the problems in Augusta and elsewhere were discovered, but it was not put under Infection Control, she said.

The e-mail itself was "somewhat alarming," she said, but when two senior clinical leaders checked into the allegations, they discovered "where he was talking about a deficiency was not a deficiency."

Much of the early discussion focused on having an appropriate space with the right kinds of ventilation for decontamination and sterilization, which was not an immediate patient safety issue, hospital epidemiologist Stephanie Baer said.

"Yeah, we had some quality improvement to do," Baer said. "I think we all would agree with that. But the level of alarm to stop all procedures, there was not an immediate danger to patients identified at that time to justify that degree of reaction. When we did identify a problem that was potentially a safety problem for patients, we immediately closed the clinic. And that was appropriate."

The kind of sterilization being discussed in April was different from the kind used in the ear, nose and throat clinic, so the changes suggested wouldn't have caught the problem right away, she said.

When Augusta VA Director Rebecca Wiley testified last year before the House Committee on Veterans Affairs, she referred to the April discussion and e-mails as "some questions or controversy over where the supervisory responsibility needed to be for (the reprocessing department) in the future." She has said that she stands by that characterization.

New oversights in place

The VA has changed to the more-centralized kind of processing of the flexible scopes "just to improve oversight, not because it was a mandate," Baer said.

Things are working better, and a team meets monthly to ensure that all manufacturers' cleaning guidelines on all reusable equipment are being followed, Harbeson said.

"I think it's important to recognize that we identified a problem here that was common to every health care facility, VA or non-VA," she said. "And thus you've seen a growth in the industry of companies that provide oversight and assistance in the sterilization of reusable medical equipment."

The VA has learned from its mistakes, Baer said.

"Of course we deeply regret that we had to place any patient in this situation," Harbeson said. "We do believe that we have handled this in the best way we could have."

Marana left the VA before the problem was discovered in the ear, nose and throat clinic and said he hasn't really kept up with what has happened.

"Whether it was corrected or not, I don't know," he said. "All I got was, things have changed or a lot has changed since I left. Whether those issues have been addressed, I have no idea."

The back story

BACKGROUND: More than 10,000 former VA patients -- including 1,200 treated at the Charlie Norwood VA Medical Center -- have received warnings that improperly sterilized equipment might have exposed them to infections.

DEVELOPMENTS:

- In November 2008, an Augusta VA patient noticed a nurse in the Ear, Nose and Throat clinic cleaning an endoscope with a solution not recommended by the manufacturer. The patient's concerns reached the Augusta VA's chief of surgery, who closed the clinic the next day for a week. An investigation in Augusta later led to the discovery of problems at VAs in Miami and Tennessee.

- In February 2009, the health system announced that about 1,200 veterans might have been exposed in Augusta. The patients were alerted and advised to get blood tests for HIV and hepatitis.

- In June 2009, Augusta and regional VA officials appeared before the U.S. House Committee on Veterans' Affairs oversight and investigations. In addition to disciplining staff, VA Secretary Eric Shinseki said he would require center directors to verify in writing that they are complying with guidelines.

- In July 2009, a Department of Veterans Affairs letter pledged free medical care and treatment for former patients who tested positive for HIV or hepatitis since being exposed to the endoscopic cleaning mistakes.

- Dr. Robert Jesse, the VA principal deputy undersecretary for health, said in July that at least 50 infections have turned up, but he reiterated the VA's position that it is very unlikely they came from the VA's equipment.

- Judy Yarzebinski, an Augusta VA patient who claims she contracted hepatitis C from an improperly cleaned laryngoscope, is suing for $10 million.

- In July, officials in Augusta discovered 33 patients had been overlooked when the VA alerted patients about possible exposure. Officials began contacting those patients Aug. 11.

- On Sept. 12, The Augusta Chronicle revealed that Infection Control Practitioner David Marana sent out an e-mail in April 2008 saying the Augusta VA was not following standards for the sterilization of flexible endoscopes. "At this time, I recommend that services involving reusable flexible scopes be discontinued until we have met the standards," he wrote. Two senior clinical leaders checked into Marana's allegations but did not believe there was a deficiency in the procedure.

-- From staff and wire reports

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dvdbiggs
13
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dvdbiggs 09/12/10 - 07:28 am
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Sounds like VA Management and

Sounds like VA Management and Quality Control are trying to deny the blame for mistakes, even after they were informed of the danger. Again, this is typical of Management and Quality Control.

Runner46
0
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Runner46 09/12/10 - 08:33 am
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Any government run facility

Any government run facility has a bureaucracy that is often slow to respond to a change in policy. And, too, issues of safety should reach the proper person for corrective action. In this case, slow response to a safety issue has cost the facility dearly, in time, dollars, and public perception. As of today, the problem has been corrected. We can only hope that next time a safety issue will be expedited and corrected before harm is done to patients.

Scribbles
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Scribbles 09/12/10 - 09:39 am
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The VA needs to clean house

The VA needs to clean house at the Charlie Norwood hospital, starting at the top. Instead of heeding the warnings and acknowledge the wisdom of well-educated healthcare professionals, VA administration chooses to ignore them. The director circulates politically correct announcements while her chosen administrative staff build smoke screens to create appearances of good quality healthcare for inspecting officials and hiding inferior healthcare practices. (She stammered through a channel 12 television interview when she was expected to respond directly, truthfully and spontaneously.) Some conscientious VA healthcare professionals have been conveniently reassigned to remove them and divert their focus away from solving problems. Too many leave the VA in frustration to seek employment where their expertise is respected, and good quality patient care is practiced, not used just as a catch phrase.

twentieth century man
102
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twentieth century man 09/12/10 - 10:15 am
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0
The VA is making efforts to

The VA is making efforts to deconstruct certain assertions herein. Possibly the patients contracted hepatitis C in some other way, etc. Certain aspects of the case are mysterious-why would a "patient" see the handling and sterilization of medical equipment & how would this individual recognize this process as faulty, etc.? Who was the "patient?" This issue may reflect a systematic medical problem related to the corporate, industrial conversion of the medical care system whereby generalist lay administrators direct scientifically-trained specialists: physicians, scientists, nurses, etc. Similar problems may have occurred in Las Vegas, a few years ago, resulting in the spread of hepatitis. Perhaps these problems resulted from attempts to reuse disposable equipment or to save money sterilizing autoclavable medical equipment. There was a hospital related organization associated with saving money in similar situations. The current situation shares some aspects with a "cover up."

disssman
6
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disssman 09/12/10 - 11:35 am
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So, the program isn't under

So, the program isn't under infection control department. But, they never did say what department is is under, so I assume it is under the janitorial or administrative departments.

I especially loved the information that " a Department of Veterans Affairs letter pledged free medical care and treatment for former patients who tested positive for HIV or hepatitis since being exposed to the endoscopic cleaning mistakes". Kinda like we know we may have ruined you, but you can come in for free to try to undo the mess we made of you. I wonder what the cost is for a veteran with HIV or Hep-c if they don't have good records?

MuskiePhD
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MuskiePhD 09/12/10 - 01:51 pm
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I believe Mr. Corwin and the

I believe Mr. Corwin and the staff at the Augusta Chronicle have overlooked an important news report that further supports this article's conclusions and intimations. See: "The San Juan Weekly? newspaper, page 3, June 24-30 2010 (www.myendosite.com/articles/SanJuanWeekly.pdf" Something potentially improper appears at hand. Lawrence F Muscarella PhD (a patient advocate)

corgimom
27546
Points
corgimom 09/12/10 - 03:18 pm
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0
"I especially loved the

"I especially loved the information that " a Department of Veterans Affairs letter pledged free medical care and treatment for former patients who tested positive for HIV or hepatitis since being exposed to the endoscopic cleaning mistakes". Kinda like we know we may have ruined you, but you can come in for free to try to undo the mess we made of you. I wonder what the cost is for a veteran with HIV or Hep-c if they don't have good records?"

Death, disssman.

"Hey, I have bad news/good news. While we may have done things that will kill you, the good news is that we will give you free medical care."

Wow, who would have an issue with that?

deacon302000
0
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deacon302000 09/12/10 - 03:53 pm
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There will probably be more

There will probably be more mistakes in the future. I'm a patient at the VA medical, and the nurses were on strike. They were on strike because of low staff....!!!!!WHAT..This is not just nurses. Common sense will tell you the whole hospital is stretched out with hardly NO staff...ROOM FOR MORE MISTAKES!!!!!!!!!!!!!!!!!DAHHHHHH ...That scares me as a patient ,but this is what I can afford at this time...

Sweet son
9680
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Sweet son 09/12/10 - 05:06 pm
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I am with you who think that

I am with you who think that from the top down all aspects of patient care in our Charlie Norwood VA need to be examined. Bad scopes and overworked nurses might just be the tip of the iceberg.

Nursing shortages might be because even with great benefits nurses have gotten the word that it might not be a good place to work. Maybe they are seeking employment elsewhere.

dvdbiggs
13
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dvdbiggs 09/12/10 - 08:34 pm
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Scribbles, you have stated

Scribbles, you have stated the problem at the VA very well. I have been saying the same thing for years.

I read the article referenced by Lawrence F Muscarella PhD. It does seem that the VAOIG ignored the real problem.

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