VA inspections show continued exam flaws

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By Kimberly Hefling and Ben Evans ASSOCIATED PRESS

Fewer than half of Veterans Affairs centers given a surprise inspection last month had proper training and guidelines in place for common endoscopic procedures such as colonoscopies - even after the agency learned that mistakes may have exposed thousands of veterans to HIV and other diseases.

The findings, from the VA's inspector general and obtained by Associated Press, suggest that errors in colonoscopies and other minimally invasive procedures performed at VA facilities may be more widespread than initially thought.

The report was slated to be released Tuesday at a hearing before a House Veterans Affairs subcommittee, in which VA officials are scheduled to take questions. Rep. Harry E. Mitchell, Arizona Democrat, chairman of the hearing, on Monday called the situation a "damaging blow to the trust veterans place in the VA."

Mr. Mitchell said he wants to learn what changes have been put in place to prevent similar mistakes.

Howard McIntyre, commander at one of two Disabled American Veterans chapters in Augusta, Ga., called the findings "disturbing" and said "there shouldn't have been any low level of training at all.

"As soon as it was caught, the training should have been stepped up instantly," the 67-year-old Navy veteran said. Medical care for veterans, he said, "shouldn't be any less than perfect, because these are lives we're talking about."

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," Miss Roberts said.

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

The investigation comes months after the discovery of a mistake at Murfreesboro, Tenn., 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. 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 taking the follow-up blood checks tested positive for HIV, 34 tested positive for hepatitis C and 13 tested positive for hepatitis B. 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 said the chance of infection was remote.

Sen. Richard M. Burr of North Carolina, the ranking Republican on the Senate Veterans Affairs Committee, said, "Too many questions surrounding the VA's handling of this issue remain unanswered."

The VA has acknowledged that the mistakes were caused by human error. A question has been whether the mistakes might have been repeated at other facilities using similar equipment.

In Murfreesboro, officials think use of an incorrect valve may have allowed body fluid residue to transfer from patient to patient, possibly for more than five years after the equipment was installed in 2003.

In Miami, a tube that was supposed to be cleaned after each colonoscopy was instead cleaned at the end of each day, affecting patients between May 2004 and March 2009. And in Augusta, the ENT scopes used for looking into the nose and throat weren't properly cleaned, affecting patients between January 2008 and November 2008.

Since VA reported those mistakes, a key question has been whether they might have been repeated at other facilities using similar equipment.

c Russ Bynum contributed to this report.