United States Department of Veterans Affairs
Health Care

VA Continues Reusable Medical Equipment Notification for Veterans

Augusta ENT Clinic Notifications

The Department of Veterans Affairs' (VA) primary mission is to serve our Nation's Veterans. 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. In the past 18 months, VA has implemented a more stringent oversight for reusable medical equipment to ensure a safe environment. 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 proper administrative and disciplinary measures are taken.

Last year, VA contacted 1,069 Veterans who received nose and throat procedures with certain types of equipment at the Charlie Norwood VA Medical Center, in Augusta (CNVAMC) between January and November 2008 to offer screening for potential viruses due to reusable medical equipment that was not reprocessed according to manufacturer's instructions. In July 2010, VA brought together a team of clinicians and initiated a second, more extensive review of patient records (approximately 2,300) to ensure no other patients were missed. As a result of this exhaustive search, VA has identified 33 additional patients and is offering free screening for certain viruses. This is not a new incident, but an expanded notification concerning what occurred prior to our review in early 2009. VA is making every effort to contact each and every one of these patients to explain the situation and to offer appropriate screenings. Veterans can be assured that VA remains committed to providing safe, high quality care. We are also making every effort to keep Veterans informed and to improve our processes.

Numbers of Potentially Affected Patients as of December 28, 2010*
Number of Patients Augusta
Potentially Affected (Risk Pool) 33
Notified 32
Responded to Disclosure Letter or Called VAMC for Appointment 32
Declined Testing or Appointment 0
Notified of Test Results 28
Total Calls to Toll Free Hotline or Call Center 1
*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**
Test Augusta
Hepatitis B Virus 0
Hepatitis C Virus 0
HIV 0
**These results are not necessarily linked to any reusable medical equipment issues and the evaluation continues.  We are continuing to notify individuals whose letters have been returned as undeliverable, and are working with homeless coordinators to reach Veterans with no known home address.

VA's Foremost Concern is the Safety of Patients

VA believes that safety lapses are unacceptable, no matter how small the risk. As part of the Department's commitment to reducing and preventing inadvertent safety risks to patients, personnel at the Augusta VA Medical Center have been assigned to ensure that affected Veterans receive prompt testing and appropriate counseling at no cost to the Veteran. The data on this page reflect the most current notifications, testing, and results, and will be updated when new information is available.

The Department is 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 Veterans. VA's processes lead the nation in terms of transparency and accountability.

We deeply regret that this situation occurred, and Veterans and their families can be assured VA is taking all necessary steps to make certain testing is offered quickly and results are communicated timely. VA understands the responsibility and trust Veterans place in us. Staff across VA is doing everything possible to address this situation and prevent them from occurring again.

Read about VA's national improvements to SPD processes.