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http://www.navytimes.com/news/2009/06/ap_veterans_colonoscopies_061609w/

VA to face questions on colonoscopies


By Ben Evans - The Associated Press
Posted : Tuesday Jun 16, 2009 4:38:09 EDT

WASHINGTON — The questionable medical practices were first found at a Veterans Affairs medical center in Tennessee, then at VA facilities in Georgia and Florida.

Now, Veterans Affairs officials will face fresh questions about patient safety at a House hearing Tuesday after an internal review found continued weaknesses with colonoscopies and other procedures at the agency’s medical centers.

The latest findings — that fewer than half of VA facilities selected for surprise inspections in May had proper training and guidelines in place — are contained in an inspector general’s report to be released at the hearing. The findings, obtained in advance by The Associated Press, suggest that errors in colonoscopies and other minimally invasive procedures may be more widespread than initially believed.

The report comes months after the agency learned that mistakes at three centers in Georgia, Florida and Tennessee may have exposed thousands of veterans to HIV and other diseases. Rep. Harry Mitchell, D-Ariz., who will chair the hearing, on Monday called the situation a “damaging blow to the trust veterans place in the VA.”

Mitchell said in a statement he wants to learn what the VA is doing to protect those potentially exposed and what changes have been put in place to prevent similar mistakes.

VA requirement

Agency spokeswoman Katie Roberts said the VA is strictly enforcing a requirement that each facility verify that it’s implementing correct standard operating procedures.

“We are outraged at these results, of course, and are taking aggressive action to fix this problem quickly and effectively,” Roberts said in a statement.

The random inspections were conducted May 13-14 at 42 VA medical centers around the country. They found that just 43 percent of the centers have standard operating procedures in place and have properly trained their staffs for using endoscopic equipment.

Earlier this year, the discovery of a mistake at a Murfreesboro, Tenn., facility led to a nationwide safety campaign at the VA’s 153 medical centers, calling attention to potential infection risks from improperly operating and sterilizing the equipment.

Along with Murfreesboro, the agency has said mistakes were identified at a Miami center and at an ear, nose and throat clinic in Augusta, Ga. In February the agency started warning about 10,000 former patients at those facilities, some who had colonoscopies as far back as 2003, to get blood tests for HIV and hepatitis.

As of Friday, the VA reported that six veterans who took the follow-up blood checks tested positive for HIV, 34 tested positive for hepatitis C and 13 tested positive for hepatitis B. But there is no way to prove whether the infections came from VA procedures, and some experts say most or all of the infections probably already existed. The VA says the chance of infection was remote.

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