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Hearing Set To Probe VA Mistakes

June 15, 2009

Mistakes at three VA hospitals potentially exposed 10,000 veterans to health worries, and now officials at the Department of Veterans Affairs have to face a congressional panel on Tuesday.

“Somebody is going to have to take responsibility,” said U.S. Rep. Phil Roe of Tennessee, the ranking Republican on the House Committee on Veterans’ Affairs’ oversight and investigation subcommittee.

The subcommittee hearing in Washington D.C. will discuss the endoscopic equipment mistakes at VA hospitals in Miami, Murfreesboro, Tenn., and Augusta, Ga.

Insiders say the VA inspector general conducted a random check on 42 VA locations.

Roe, who is a private physician, has questions about whether the problems were isolated to three hospitals or were more widespread.

“I think this was an institutional breakdown,” Roe said.

Since February, the VA has been warning about 10,000 former patients, some who had colonoscopies as long ago as 2003, to get blood tests for HIV and hepatitis.

The VA reported 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.

All but 724 affected patients have been notified of test results, according to the VA.

VA spokeswoman Katie Roberts did not respond to repeated requests for comment Thursday and Friday.

The initial discovery of an equipment mistake at Murfreesboro led to a nationwide safety “step-up” by the VA at its 153 medical centers.

The VA says the problems have been discussed with the equipment manufacturer, Olympus American.

The VA’s chief patient safety officer, Dr. Jim Bagian, said its unknown if the patients with HIV and hepatitis were infected because of improperly operated or cleaned endoscopic equipment.

Bagian has also said all the mistakes were human error.

Roe said he believes the VA has been open with the public since discovering the mistakes in December.

“These people did not intentionally do anything wrong,” he said.

However, full disclosure is not certain when private-sector hospitals discover mistakes, according to Barbara Rudolph, director of The Leapfrog Group, which promotes quality health care.

She said private hospitals also have spread infectious diseases with unsterile equipment, but there’s no national regulation requiring disclosure.

“Some hospitals have become very open and have made a commitment to be transparent about things like that,” she told the Associated Press. “There are a number of hospitals who would not have gone as far as the VA has gone.”

Michael Sheppard, a Nashville lawyer who represents dozens of veterans among the affected VA patients, wrote in a June 3 letter to the committee that it was “hard to describe the upheaval and injury this has caused innocent veterans.”

“Some no longer trust or have confidence in the VA medical facilities and feel betrayed, misled and ill-informed,” Sheppard wrote.

He also added other patients may avoid colonoscopies for fear of HIV or other infections.

A spokesman for the American Society for Gastrointestinal Endoscopy, Dr. David A. Greenwald, said that the VA patients who recently tested positive could have had the viruses for years without showing symptoms.

Greenwald said the positive tests for HIV and hepatitis C reported by the VA are far below the frequency of positive tests reported from studies of other groups of veterans.

The same is likely true of the hepatitis B cases, according to Greenwald.

“Probably all of the infections that are being reported are infections people already had,” Greenwald said.

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