Effort to notify and test as many as 10,555 patients is under way

Reforms in the healthcare system are requiring fundamental changes in how hospitals and other healthcare providers, including clinical laboratories, report medical errors. At the same time, consumers are tracking the quality differences between providers and insisting on more accountability for medical errors.

These points were highlighted in a Dark Daily e-briefing on March 11, 2009, titled “Medical Errors Become a Headline News Item.” At that time, the Department of Veterans Affairs (VA) had made public the discovery of multi-year problems at VA clinics in Murfreesboro, Tennessee, and Augusta, Georgia. At both sites, improper procedures with diagnostic equipment had been identified. In both situations, the problems meant that thousands of patients may have been exposed to infection.

The VA has been tracking down patients possibly affected by these medical errors. It is offering free laboratory tests and free medical care. In a public statement, it said “VA patients, who believe that they may have been exposed to cross contamination, were patients who received endoscopic procedures at the VA’s Murfreesboro, Tennessee, facility from April 2003 to December 2008; or at the VA’s Augusta, Georgia, hospital from January 2008 to November 2008; or at the VA’s Miami, Florida, hospital from May 2004 to March 2009.” To ensure that veterans get prompt testing and appropriate counseling, the VA added personnel at its hospitals in Murfreesboro, Augusta, and Miami.

This Dark Daily e-briefing is to update our readers on what has happened since the first public announcement of these medical errors. CNN reported that the Department of Veterans Affairs is investigating whether improperly sterilized endoscopy equipment caused one patient to test positive for HIV. The investigation came at the request of Senator Bill Nelson (D-Florida), after 10,555 veterans were possibly exposed to HIV and hepatitis B and C at three VA facilities while undergoing colonoscopies and other procedures with equipment that had not been properly cleaned.

As of April 1, 2009, the VA reported that 17 veterans had tested positive for hepatitis B, hepatitis C, or the human immunodeficiency virus (HIV). Five veterans tested positive for hepatitis B virus, eleven for hepatitis C; and one for HIV. Of the positive test results, eleven were tested at VA’s Murfreesboro facility, and six were tested at VA’s Augusta, Georgia, hospital. It has not been determined that, for the patients who tested positive, there is any relationship between these patients’ conditions and the endoscopy procedures they had. The VA said it is conducting an epidemiologic investigation into the possibility of such a relationship.

In an editorial, The Miami Herald said the VA investigation is justified. “These audits and more are necessary,” the newspaper said. “Putting lives at risk through carelessness is inexcusable. Using good sterile technique is the first and most important thing that all healthcare professionals learn-and with good reason. Failure to do so can kill patients. This is why it is so stunning and so completely unacceptable that equipment at several Veterans Administration hospitals, including in Miami, may have been improperly cleaned, exposing thousands of veterans to possible hepatitis or HIV infections.”

The Las Vegas Sun also had an editorial, saying it is time for the federal Centers for Disease Control and Prevention to study why medical staffs keep repeating basic mistakes. “Additionally, states should more tightly regulate and more frequently inspect medical facilities, and prosecutors should aggressively seek criminal convictions when notifications are necessary because of negligence or a desire to cut costs,” wrote the Las Vegas newspaper.

These events show why the campaign to eliminate medical errors is such a difficult and complex undertaking. It is an unwelcome situation for both providers and patients, and causes concern in the communities where such medical errors occurred. At the same time, discovery and recognition of medical errors is the necessary first step, because it then allows the provider to determine the root cause of the medical errors and take corrective action to reduce or prevent such errors in the future.

Related Articles:

VA looking into possible contamination at medical facilities

VA confirms local patients infected

Sloppy procedures put lives at risk

Instances of patients needing warning of possible deadly exposure keep recurring

VA Continues Notification Process for Veterans Affected by Reprocessing Issues

Medical Errors Become a Headline News Item