Patient spurred Augusta VA inquiry

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A sharp observation by a VA patient led the Charlie Norwood VA Medical Center to uncover problems with the cleaning of endoscopic equipment in November, the first of three major incidents at VA facilities that led to a congressional hearing Tuesday.

About 10,000 veterans have been or will be notified that they might have been exposed to improperly sterilized equipment at the Augusta VA and VAs in Miami and Murfreesboro, Tenn. Subsequent testing has turned up more than 50 infections among veterans, including six with HIV, although VA officials have said it is almost impossible to know whether those resulted from the exposure.

Agency officials apologized for the continued weaknesses and told a House subcommittee they would do better. VA Secretary Eric Shinseki said he would be disciplining staffers.

On Nov. 4, according to a report from the Department of Veterans Affairs Office of Inspector General, a patient had undergone a procedure in the Ear, Nose and Throat clinic at the Augusta VA and was watching the nurse clean the equipment with a sanitizing wipe. The patient noticed from the directions on the sanitizer box that it was not to be used to clean equipment that comes into contact with mucous membranes, and the patient pointed that out.

The patient's concerns reached the Augusta VA's chief of surgery, who closed the clinic the next day for a week. A subsequent investigation resulted in a decision in January to notify patients of the potential exposure, which the Augusta VA traced back to a new nurse taking over in that area in January 2008. Medical Center Director Rebecca Wiley told the congressional subcommittee that the sanitizer used is actually stronger than the one suggested by the manufacturer, according to a news release Tuesday from U.S. Rep. Paul Broun, R-Ga.

While changes were made and procedures rechecked across the VA system, including Augusta, the inspector general found during a visit to Augusta in May that there was no documentation of "device-specific competence," according to the report.

Because it had already received a site visit, Augusta was not among the 42 VA sites that received surprise visits from the inspector general's investigators in May. Only 43 percent of those sites could show they had the procedures in place to properly clean the endoscopic equipment.

John Daigh, the VA's assistant inspector general, who led the review, said the findings "troubled me greatly."

After Tuesday's hearing, Mr. Shinseki issued a statement calling it "unacceptable that any of our veterans may have been exposed to harm as a result of an endoscopic procedure."

In addition to disciplining staff, he said he would require center directors to verify in writing that they are complying with guidelines.

Associated Press reports were used in this story.

Reach Tom Corwin at (706) 823-3213 or tom.corwin@augustachronicle.com.

Read the report

-The VA inspector general's full report

-Problems in Augusta: Page 17 and Page 18

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