United States Department of Veterans Affairs

VA Continues Endoscopic Procedure Notification for Veterans

UPDATE

The VA Office of Inspector General (IG) has completed a thorough investigation of 129 medical sites to ensure proper documentation and compliance of manufacturer’s reprocessing instructions. We are pleased to announce the IG discovered only one discrepancy, a mere typographical error, of all medical sites reviewed. For additional information, including complete investigation results, please view the official IG report.

The VA is committed to comply with the International Organization for Standardization (ISO) principles to implement processes and corrective actions across the nation and to systematically eliminate identified patient risks and improve performance. VA is also committed to transparency, sharing lessons learned from this process with the public sector and with the private health care industry, with the intent of improving care for all patients.

VA reached out to over 10,300 patients who were potentially affected by these events and were able to contact, and offer testing and treatment to 99% of these patients. VA’s efforts included checking our electronic medical records, a rigorous mail and phone campaign, as well as local community outreach.

VA has held 41 employees accountable for these events and has initiated disciplinary action, with additional investigations still underway.

On December 1, 2008, VA’s Tennessee Health Care System, located in Murfreesboro, TN, identified a problem related to the reprocessing of endoscopy equipment. *

Subsequently, all VA facilities were told to review their processes to ensure that they were in compliance with the manufacturer’s instructions. Completed in December and January, these reviews also identified significant reprocessing issues at the Augusta VA Medical Center and at the Miami VA Medical Center, both of which required patient notifications and testing.

Those who may have been exposed to cross contamination were patients that received endoscopic procedures at the:

  • Murfreesboro GI Clinic from April 2003 to December 2008;
  • Augusta ENT Clinic from January 2008 to November 2008; and
  • Miami GI Clinic from May 2004 to March 2009

VA will continue to notify, inform, and treat all potentially impacted Veterans, regardless of risk, cause, or harm. Many people incur injury as a result of medical errors that could have been prevented - Unfortunately, many health care organizations do not voluntarily disclose their problems to patients or the broader public. In contrast, it is VA’s policy to actively seek out quality problems, discuss them openly, and tackle them head on.

“VA is clearly an international leader in its ethical and transparent disclosure practices. I’m very impressed with all they’re doing to ensure quality and safety for patients. The VA's approach to disclosure sets an admirable and very high standard for openness-I hope the rest of health care will follow VA’s lead.” Stated Thomas Gallagher, MD, Associate Professor of Internal Medicine at the University of Washington and a nationally recognized expert on disclosure of errors to patients.

VA is widely recognized by safety experts and ethicists as leading the nation in the practice of disclosing errors to patients in a thoughtful and compassionate way. As Ellen Fox, MD, VA’s Chief Ethics in Health Care Officer, explains, “I’m proud of VA’s disclosure policy. Being honest and open with patients and with the public is the only way to ensure the quality and safety of the health care we deliver. Sometimes this makes us an easy target. But it’s the right thing to do.”

* small low risk event at Mountain Home, TN has revealed no positive tests