July 1, 2010
Lessons learned from St. Louis VA Medical Center are applied VA-wide
WASHINGTON – The Department of Veterans Affairs’ (VA) primary mission is to serve our nation’s Veterans. President Obama has charged the Department with ensuring the VA medical network is a top-notch health care system.
“The mistakes made at the St. Louis VA Medical Center are unacceptable, and steps have been and continue to be taken to correct this situation and assure the safety of our Veterans. VA will not tolerate risk to our Veterans,” said Veterans Affairs Secretary Eric K. Shinseki. “VA employees at the St. Louis VA Medical Center, along with all of our employees, have a solemn responsibility to provide safe, quality care for the well being of all our patients.”
Under the Obama Administration, in the past 18 months, VA has implemented more stringent oversight of the safety of all its medical facilities. It is this more rigorous standard that directly led VA to identify and address problems at the St. Louis Medical Center. Additional resources have been allocated and new procedures and stricter enforcements are in place to ensure the safety of all Veterans who seek care at VA facilities. VA mandates transparency and accountability in its handling of mistakes or failures to meet VA’s high standards. VA’s processes lead the nation in terms of transparency and accountability.
“VA is committed to ensuring that all our health care facilities are safe,” said Shinseki “VA will continue to investigate the actions of individuals involved and the proper administrative and disciplinary measures will be taken.”
The St. Louis facility has undergone a thorough examination, and many safeguards are in place that are designed to prevent a similar situation from occurring again. In-depth staff training and management reviews were immediately conducted by the St. Louis leadership, medical staff, and VA’s Supply, Processing and Distribution (SPD) program office teams.
“The Veterans we serve are our friends, our neighbors and a part of our family,” said Dr. Robert Petzel, VA's Under Secretary of Health. “Under the direction of Secretary Shinseki I have determined there is a need for an independent, national Administrative Investigation Board (AIB) to determine the reasons for failure to follow correct procedures. The Chief of Dental Services has been placed on administrative leave pending the outcome of the investigation.”
Immediate actions were taken to ensure all personnel were properly re-trained and all equipment is being handled in accordance with manufacturers’ instructions. All pre-washing of dental equipment which was performed by dental personnel prior to sterilizations is now being done by qualified SPD staff.
No Veterans are currently ill as a result of this incident. The potential risk to Veterans is extremely low.
“The St. Louis VA Medical Center provides excellent care to more than 50,000 Veterans a year, and the dental clinic equipment issue does not reflect the level of care provided by the more than 2,600 dedicated medical center staff,” added Petzel.
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