The Department of Veterans Affairs' (VA) primary mission is to serve our Nation's Veterans. Our Veterans can be assured that VA remains committed to providing safe, high quality care. VA's high standards for quality and patient safety mandate transparency and accountability in its handling of mistakes or failures.
During the course of a routine inspection of the St. Louis VA Medical Center (VAMC), staff found that certain dental instruments had been cleaned in a way different than that recommended by the manufacturers. Errors made in the proper cleaning of medical equipment are unacceptable. VA is making every effort to contact each and every patient potentially affected to explain the situation and to offer appropriate screenings. Screenings and treatment will be at no cost to those affected.
In the past 18 months, VA has implemented more stringent oversight for reusable medical equipment to ensure a safer environment for patient care. In each case where VA or others discover safety or quality of care issues, VA investigates the incident and the actions of individuals involved, notifies affected Veterans and assures that proper corrective, administrative and disciplinary measures are taken.
VA is committed to keeping processes transparent so Veterans and their families never need question our commitment to their care. The data on this page reflects the most current notifications, testing, and results.
|Numbers of Potentially Affected Patients as of January 25, 2011*|
|Number of Patients||St. Louis|
|Potentially Affected (Risk Pool)||1,812|
|Responded to Disclosure Letter or Called VAMC for Appointment||1,750|
|Declined Testing or Appointment||143|
|Notified of Test Results||1,606|
|Total Calls to Toll Free Hotline or Call Center||2,656|
|*These numbers are based on the most current analysis of test results and notifications as of the date stated above. While every effort is made to provide exact numbers, the nature of medical science may result in shifts of this data as new results are determined.|
|Newly Diagnosed and Have Been Notified**|
|Hepatitis B Virus||2|
|Hepatitis C Virus||2|
|**These results are not necessarily linked to any reusable medical equipment issues. VA is performing extensive epidemiological testing to determine the time period and to the extent possible, source of known infections. Regardless of time period or source of known infections, VA will provide all related health care at no cost to infected Veterans. We are continuing to notify individuals and are working with homeless coordinators to reach Veterans with no known home address.|
VA believes that safety lapses are unacceptable, no matter how small the risk. The St. Louis VAMC provides excellent health care to more than 50,000 Veterans a year, and the dental clinic equipment issue does not reflect the level of care provided by more than 2,600 dedicated staff there.
As part of the Department's commitment to reducing and preventing inadvertent safety risks to patients, personnel at the St. Louis, MO Medical Center have been assigned to ensure that affected Veterans receive prompt testing and appropriate counseling at no cost to the Veteran. VA has learned from past public notifications and has improved testing and reporting processes by including epidemiological studies to determine the age, and to the extent possible, the source of infections. In St. Louis, VA honored the requests of some Veterans who preferred to have their blood work drawn, at VA expense, at a private laboratory of the Veteran's choice. Some of those Veterans may require additional blood work to ensure the required epidemiological testing is done to meet VA standards. VA will personally contact any Veterans in need of additional laboratory work. Again, any additional lab work would be at no cost to the Veteran.
The Department takes pride in its recognition as a leader in the health care industry in developing and nurturing a culture of safety at all its facilities. Patient safety managers at all 153 VA hospitals are leading efforts to reduce and eliminate safety risks. Although the risk of cross contamination and exposure to these infections is statistically low, our policy is to treat all Veterans potentially affected, regardless of risk, regardless of cause and without cost to our Veterans.
We deeply regret that this situation occurred and be assured VA is taking all necessary steps to make certain testing is offered quickly and results are communicated in a timely, compassionate manner. VA understands the responsibility and trust Veterans place in us. Staff across VA are doing everything possible to address this situation and prevent it from occurring again.
News Release: http://www.va.gov/opa/pressrel/pressrelease.cfm?id=1918
Read about VA's national improvements to SPD processes.