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washingtonpost.com

Negligence Suits Likely Over VA Procedures: 3 Hospitals Used Dirty Equipment


By Steve Vogel
Washington Post Staff Writer
Monday, August 24, 2009

Army veteran Juan Rivera reported to the veterans hospital in Miami for a routine colonoscopy in May 2008. Almost a year later, the 55-year-old father of two learned that the Department of Veterans Affairs had not properly sterilized the equipment used for the procedure.

A test then revealed that he had been infected with HIV. "The VA has issued me a death sentence," Rivera said, according to his attorney.

A problem with sterilization practices at a VA facility in Tennessee was discovered in December, and the department has notified more than 11,000 veterans who had endoscopic procedures at three of its facilities that they may have been exposed to cross-contamination. VA has advised them to return for testing.

As of Aug. 3, eight of those patients have tested positive for HIV, 12 for hepatitis B and 37 for hepatitis C, according to VA.

Rivera, who served in the Army for 13 years and drives a truck for the U.S. Postal Service, filed notice last month of his intent to sue VA. The administrative claim, filed with VA under the Federal Torts Claim Act, says his infection was caused by the department's failure to clean its equipment and to follow proper procedure.

"He's angry, stunned and distraught that the government he served so well for so long has done this to him," said his attorney, Ira Leesfield.

Lawyers predict that Rivera's case marks the beginning of a rush of lawsuits against VA alleging negligence in the handling of medical equipment.

Nashville lawyer Mike Sheppard said Friday that he is preparing to file claims on behalf of a dozen veterans who have contracted hepatitis B or C, as well as 50 to 60 emotional-distress claims from veterans and family members.

VA, while promising full care for those infected, has said that no link has been established between the patients' conditions and the endoscopy procedures.

The department referred a request for comment to its Web site, U.S. Department of Veterans Affairs, where it provides updates on patient testing. "VA will continue to notify, inform, and treat all potentially impacted veterans, regardless of risk, cause, or harm," says a posted statement.

The sterilization problem came to light when officials at the VA Medical Center in Murfreesboro, Tenn., learned that workers were sanitizing endoscopy equipment at the end of the day instead of after each procedure. The manufacturer of the equipment recommends a cleaning after each use.

"This is just a question of neglect and sloppiness," Leesfield said. "They just run people through like a mill."

All VA facilities were subsequently instructed to review their procedures and identify problems.

Based on the review, VA announced that patients who underwent endoscopic procedures in Murfreesboro from April 2003 to December 2008; in Augusta, Ga., from January 2008 to November 2008; and in Miami from May 2004 to March of this year may have been exposed to cross-contamination.

But the problems could extend beyond those locations. In April, the VA inspector general sent investigators on unannounced inspections at 42 of the department's medical facilities. Its report, released in June, concluded that only 43 percent were in compliance.

"Facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans," the report said. "The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure."

Sheppard said the revelations have triggered a crisis of confidence in VA among many veterans. "They just don't trust what they've been told," he said.

"The bad side of this is patients will shy away from colonoscopies if they don't trust the VA," Sheppard said.
 

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washingtonpost.com

The sterilization problem came to light when officials at the VA Medical Center in Murfreesboro, Tenn., learned that workers were sanitizing endoscopy equipment at the end of the day instead of after each procedure. The manufacturer of the equipment recommends a cleaning after each use.

Ya think?!

:aargh4:
 

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I've seen better hygiene practised in tattoo parlors.
 

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"The bad side of this is patients will shy away from colonoscopies if they don't trust the VA," Sheppard said.
No, the bad side is that 8 patients now have HIV, 12 have hepatitis B and 37 have hepatitis C.
 

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And people want to trust the government with universal health care, what could go wrong?:rolleyes:
 

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Holy crap I go to the VA but never had the procedure,I believe mine will be done by a civilian doctor.
 

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Somebody needs to say it. Vets, particular Vietnam era and into the mid 80's, have a high instance of Hep B & C due to the countries that they served in. There's a very real chance that some were already infected with a virus. Out of 11,000 tested 57 is only a .005% infection rate and probably in line with national numbers.

I'm familiar with VA hospitals and it's a hazardous place for the healthcare workers too. Accidental sticks happen and with a group prone to carry these viruses, it's a very real threat.

Don't get me wrong, this was an extreme breach of infection control protocols and the person(s) responsible and especially the supervisor of should be shown the door immediately. Vets deserve the best care possible and that's not possible when the most basic safety procedures aren't followed.

If those vets infected, were infected by the procedure, then they deserve compensation. Probably as much as the patients infected by the Hep C infected scrub tech at Rose Medical Center (not VA) that injected patients with saline after injecting the pain killers into herself with the same needle. It unfortunately happens everywhere.
 

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The VA system sucks, based on what I've seen transporting patients in and out. The government and the people would be much better served by giving veterans comparable insurance cards and closing the VA system down.
 

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"VA will continue to notify, inform, and treat all potentially impacted veterans, regardless of risk, cause, or harm," says a posted statement.
I just thought that was a poorly chosen word, still sorta humorous.
 

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I am a disabled veteran rated at 70 percent. Yep, I work on a good job every day. Was treated by the VA for many years. Dozens of times the VA sent me the wrong meds. The VA sent me wrong meds that could have killed me. Had to check every pill against the PDR to make sure it was what the label on the bottle said it was. Many 09:00 appointments turned into 16:00 appointments or no appointment at all.

The VA hospital in Oklahoma City has tha atmosphere of a mortuary. The place really does stink. The staff exudes an attitude of uncaring incompetence. Disabled veterans wait 2-3 hours just to have their blood drawn.

This thing with the endoscopes can be attributed to the general laxity, incompetence and poor attitude of many VA employees. My long time friend Ralph retired from the Army with a disability, later retired from US civil service and went to the Oklahoma City VA hospital and the VA clinic in Lawton, OK for his health care. The Lawton clinic ordered chest X-rays for Ralph: The X-Rays were done by the Reynolds Army hospital at Ft. Sill. They were read by the Army doctor and a letter was forwarded to the VA clinic with the X-rays.

Twice Ralph had X-rays at Ft. Sill. Twice the Ft. Sill radiologist told the VA in a letter that Ralph had a huge spot on his lung. The VA forgot to tell Ralph-these incidents happened one year apart.

Finally talked Ralph into seeing my physician. The Dr. had a chest Z-ray done and found a spot big as a half dollar on his lung. The Dr. Went to the VA clinic and looked at Ralph's X-rays and the letters from the radiologist at Ft. Sill. Ralph sued the VA and the VA just handed him over $600,000. But money is no good to a dying man.
 

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The VA system sucks, based on what I've seen transporting patients in and out. The government and the people would be much better served by giving veterans comparable insurance cards and closing the VA system down.

The VA has over 1400 clinics, hospitals and nursing homes. It's frustrating to hear a person complain about a particular VA hospital and it's attached to the whole VA system. Mistakes are made in every hospital around the world and it's just attached to that hospital.
Are people honestly that naive to think mistakes aren't made in civilian hospitals.

As stated before, I am very familiar with the VA and while it's not perfect, it provides a valuable resource to our veterans. Every effort is made to provide the best care and there are many veterans thankful for the care they receive.
 

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The people responsible for this gross negligence should get the death sentence applied. I'm tired of this garbage.
 

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Maybe you missed this tidbit:

In April, the VA inspector general sent investigators on unannounced inspections at 42 of the department's medical facilities. Its report, released in June, concluded that only 43 percent were in compliance.

As was explained to me when I got shoddy medical care (not at a VA), people can only expect the accepted standard of care from medical professionals, which is the minimum acceptable level of care. 57% of tested VA facilities failed to meet that minimum.
 

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Personally I believe vets, myself included should be given vouchers to receive their care in civilian facilities.

I think the only government run health care worse than the Veterans Administration would be the government health care provided to the Native Indian population on the country's Reservations.

And we are on the brink of government run health care for everyone!
 

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Anyone who really cares about veterans should read Wounded Men, Broken Promises by Robert Klein. That book is just as pertinent now as when it was written in 1981. I often talk with young wounded veterans and hear of the hassles that they have to go through just because they stood up, signed on the dotted line and fought for the USA.

Bottom line: The VA remains a badly broken system that will not be fixed short of a complete housecleaning. One third of VA doctors are immigrants who are not conversant in English. Many are not board certified physicians.
 

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The VA system sucks, based on what I've seen transporting patients in and out. The government and the people would be much better served by giving veterans comparable insurance cards and closing the VA system down.
Wait a minute Hoss before you start closing VA hospitals down based upon the incident in Tennessee. As a lawyer who has handle federal tort claim suits against the VA and similar actions againt private hospital AND also is a VA patient, I can tell you that if your standard is to close down all VA hospitals for something that happened in Tennessee, we might as well close down all hospitals in the U.S. No hospital is permanently immune from these type of fiascos, and most at some time or another have outbreaks of some type, particularly unexplained staf infections.

Overall the VA system has improved vastly in the last decade. Their mega computer system is one of the best in the world. The turtle has finally caught up with the hare, and in many instances has surpassed the hare.
 
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