Lawmakers sharply criticized the Veterans Affairs Department on Tuesday about why a national scare over botched colonoscopies earlier this year didn't prompt stronger safeguards at the agency's medical centers.
Agency officials apologized for the continued weaknesses and told a House subcommittee they would do better. VA Secretary Eric Shinseki said he would be disciplining staffers.
The strong reaction came as the agency's inspector general reported that fewer than half of VA facilities selected for surprise inspections last month had proper training and guidelines in place. That was months after the VA launched a nationwide safety campaign over the discovery of errors at facilities in Miami, Augusta, Ga., and Murfreesboro, Tenn., that could have exposed veterans to HIV and other infections.
John Daigh, VA's assistant inspector general who led the review, said the findings "troubled me greatly."
"We think there are systemic issues," Daigh said.
Providing new details on the mistakes found at Miami's center, for example, the report said workers there didn't know for almost five years that they should have been sterilizing an irrigation part on an endoscope used for routine colonoscopies. They also weren't cleaning a water tube between each procedure as recommended by the manufacturer and were mistakenly attaching the water system to the scope during the colonoscopy instead of before, possibly allowing contamination of sterile components.
The errors — all discovered after the hospital reported in January that it was using its equipment properly — illustrate the potential reach of the problem, not just at VA but in the private sector. Hospitals across the country are using different equipment, training and guidelines. Even as equipment changes, many staffers have continued using the same cleaning practices, James Bagian, VA's chief patient safety officer, said after the hearing.
"You don't know you're wrong until you know you're wrong," Bagian said when asked if the agency is confident that mistakes were limited to the three states that have reported problems.
In February, the VA began warning about 10,000 former patients in Georgia, Tennessee and Florida — some who had procedures as far back as 2003 — that they may have been exposed to infections. Although the VA says the chance of infection was remote, the patients were advised to get blood tests for HIV and hepatitis.
The agency says six veterans subsequently 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 has said — through self-reporting from individual facilities — that it believes errors were limited to the centers in the three states. But the inspector general report suggests otherwise.
In surprise inspections at 42 randomly selected medical centers on May 13 and 14, investigators found that only 43 percent had standard operating procedures in place for the specific equipment in use and could show they properly trained their staffs for using the devices.
Lawmakers expressed disbelief that administrators hadn't immediately tightened procedures after the safety alert earlier this year.
"You certainly would think that after the initial discoveries and the directive from the VA that medical directors would make sure that all of their equipment and procedures were brought into line," said House Veterans Affairs Committee Chairman Bob Filner, D-Calif., who nonetheless praised the VA for being transparent. "There will be a public accounting of this situation."
VA officials struggled to explain the findings and said they would overhaul procedures so that medical centers follow more uniform practices.
After the hearing, Shinseki issued a statement calling it "unacceptable that any of our veterans may have been exposed to harm as a result of an endoscopic procedure."
Along with disciplining staff, he said he would require center directors to verify in writing that they are complying with guidelines.
Several top VA officials with experience at private hospitals said similar discoveries in the private sector would not have been publicized without specific knowledge that a patient was harmed.
Daigh said his investigators tried unsuccessfully to get information about potential problems at private hospitals, and several lawmakers said they think the problem probably extends beyond the VA.
"If this is happening in VA, what is happening ... in our greater health system?" asked Rep. Steve Buyer of Indiana, the top Republican on the committee.