VA Hospitals Potentially Exposed 2,609 Veterans to Infections Such as HIV and Hepatitis, According to GAO

By Edwin Mora | September 28, 2010 | 9:56 AM EDT

The GAO says that VA hospitals potentially exposed 2,609 patients to infections. (Photo from VA web site)

( - Veterans Affairs hospitals—which are health-care facilities owned and managed by the federal government--potentially exposed 2,609 patients to infectious diseases such as HIV, Hepatitis B, and Hepatitis C because they treated them with incorrect or improperly sanitized equipment, according to congressional testimony presented last week by the Government Accountability Office.

At one VA facility, 83 veterans were given dialysis with a machine that was fitted with a part that allowed blood to pass through where it should not have, potentially exposing them to infection by blood-borne diseases. Later, these 83 veterans were tested and none were found to be infected.

At another VA facility, 2,526 veterans were given colonoscopies with equipment that had not been properly sanitized. As of mid-August, 2,523 of these veterans had been notified and tested for infections. Seventeen were discovered to have “new positive test results,” which the VA insists, however, “are not necessarily linked” to their treatment with the improperly sanitized equipment.

The GAO reported on these problems after investigating the VA’s procedures for dealing with “reusable medical equipment” (RME) and expendable medical supplies at five Veterans Affairs medical centers (VAMC). On Thursday, Debra A. Draper, the GAO’s director for health-care issues, presented written and oral testimony about the GAO’s findings to the House Veterans Affairs Subcommittee on Health.

“At one of the five VAMCs we visited, VAMC officials discovered that one staff member working in a dialysis department purchased specialty supplies without obtaining the required signature of an appropriate approving official,” Draper said in her written testimony. “That staff member was responsible for ordering an item for use in 17 dialysis machines that was impermeable to blood and would thus prevent blood from entering the dialysis machine. However, the staff member ordered an incorrect item, which was permeable to blood, allowing blood to pass into the machine. After the item was purchased, the incorrect item was used for 83 veterans, resulting in potential cross-contamination of these veterans’ blood, which may have exposed them to infectious diseases, such as HIV, Hepatitis B, and Hepatitis C.”

Fortunately, according to the GAO, no veterans were actually infected by this use of inappropriate equipment.

“As of June 2, 2010, the VAMC reported that all testing has been completed and that no veterans have acquired infectious diseases as a result of this incident,” Draper said in her written testimony. “The VAMC found that one of the 83 veterans identified was dialyzed on an uncontaminated machine and therefore this veteran was not notified or tested for these infectious diseases.”

In the other incident, according to Draper’s testimony, the “auxiliary water tube” used in the colonoscopes at a VA hospital “was not being reprocessed correctly”

“According to VAMC officials and the VA Office of the Inspector General, in response to a patient safety alert that was issued on the auxiliary water tube in December 2008, officials from the VAMC checked their inventory management systems and concluded—incorrectly—that the tube was not used at the facility. However, in March 2009, the VAMC discovered that the tube was in use and was not being reprocessed correctly, potentially exposing 2,526 veterans to infectious diseases, such as HIV, Hepatitis B, and Hepatitis C.”

Although this colonoscope problem was reported in the press and attracted the attention of members of Congress, a year and a half later it remained uncertain how many people were infected as a result of it.

In her written testimony, Draper noted that there were some “new positive test results” among the veterans who underwent procedures with the incorrectly reprocessed colonoscopes, but that the VA was reporting that these test results were not necessarily connected to the use of that equipment.

“As of August 17, 2010, the VAMC reported that it has successfully notified 2,523 of the 2,526 veterans of possible exposure to infectious diseases and that there were 17 new positive test results,” Draper said in her written testimony. “VA reports that these results are not necessarily linked to RME [reusable medical equipment] issues and it is continuing its evaluation.”

A VA inspector general’s report published in June 2009 identified the VA hospital in Miami, Fla. as the facility where the colonoscopes had been incorrectly reprocessed.

The GAO expects to publish a full report on VA’s purchasing and inventory practices for reusable medical equipment and expendable medical supplies in early June.