Veterans' Medical Facilities Not Sterilizing Medical Equipment Properly, GAO Finds

By Edwin Mora | May 5, 2011 | 3:55 AM EDT

The VA Medical Center in Dayton, Ohio (Photo: Veteran Affairs)

( – Department of Veteran Affairs’ guidelines dealing with sterilizing reusable medical equipment at VA medical centers are rife with weaknesses that could potentially put veterans’ safety at risk, a federal audit has concluded.

The Government Accountability Office (GAO) audit on VA health care, released on Tuesday, found the some vital pieces of equipment were not being sterilized properly.

Conducted for the period March 2010-May 2011, the audit was presented during a hearing held by the House Committee on Veterans’ Affairs.

The hearing was called to examine medical safety practices at VA medical facilities, following several safety incidents, including one at a facility in Dayton, Ohio, where hundreds of veterans had to be tested for potential infection after being treated by a dentist who was accused of not sterilizing instruments or changing disposable gloves between patients.

Last September the GAO reported that VA hospitals had potentially exposed 2,609 veterans to infectious diseases such as HIV and Hepatitis as a result of improperly sanitized reusable medical equipment.

VA operates the largest government-run health care delivery system in the U.S. It provides health care to over 5.5 million veterans each year in a system including 153 VA medical centers (VAMCs) across the nation, providing a range of outpatient, inpatient and residential services.

“In providing health care services to veterans, clinicians at VAMCs use reusable medical equipment (RME), which is designed to be reused for multiple patients and includes such equipment as endoscopes and some surgical and dental instruments,” the GAO report said.

“Because RME is used when providing care to multiple veterans, this equipment must be reprocessed – that is, cleaned and disinfected or sterilized – between uses,” it continued.

“VA has established requirements for VAMCs to follow when reprocessing RME, which are designed, in part, to help ensure the safety of the veterans who receive care at VAMCs.”

Despite those requirements, the GAO concluded that “weaknesses exist in VA’s policies for reprocessing RME that create potential safety risks to veterans.”

In particular, VA failed to specify which devices require special training for reprocessing (sterilization), according to the GAO.

The audit found that VA has issued “conflicting guidance for developing device-specific training for reprocessing RME [that] has led to confusion among VAMCs about which types of RME require device-specific training and how VAMCs should develop that training.”

“This confusion has contributed to some VAMCs not developing training for their staff for some critical and semi-critical RME,” the report said.

Critical reusable medical equipment includes surgical instruments while semi-critical ones include some endoscopes – a device with a light attached, used to look inside the human body and organs.

Due to a lack of training, staff at some VAMCs “may not have been reprocessing all RME properly, which potentially put the safety of veterans receiving care at these facilities at risk,” noted the GAO.

The audit also found weaknesses in VA oversight that prevent the department from identifying and addressing areas of noncompliance in sterilization requirements, including those occurring frequently and those that “pose high risks to veterans’ safety.”

As a result of these weaknesses, it said, VA is “unable to confirm, for example, whether VAMCs have addressed non-compliance with its operational reprocessing requirement to separate clean and dirty RME.”

VA furthermore does not know the extent to which its medical centers are following the guideline that staff must use personal protective gear when sterilizing equipment, a key requirement to ensure that sterile equipment is “not contaminated by coming into contact with soiled hands or clothing.”

The audit said it essential that VA corrects the identified weaknesses, “to prevent potentially harmful incidents from occurring.”

In a statement about Tuesday’s hearing, Rep. Jeff Miller (R-Fla.), chairman of the House Veterans’ Affairs Committee, called the situation regarding sanitization safety problems “unconscionable.”

“Imagine having survived the battlefield to return home, visit a VA hospital, only to receive a letter in the mail years later stating you may be at risk of having contracted an infectious disease because of the improper sterilization of medical equipment,” he said in a statement.

“These incidents shatter the very trust we all assume on behalf of our veterans.”

The statement expressed concern about an “apparent lack of leadership” at VA in dealing with these issues.

“The time for talk is over,” Miller said. “VA must confront these issues head on, deepen the obligation to care for the veterans affected by these incidents, and make the necessary changes within the VA healthcare system to prevent any future incidents that put our veteran patients at risk.”

Rep. Bob Filner (D-Calif.), the ranking member of the House Committee on Veterans’ Affairs, called on the VA to fix the “culture of secrecy and cover-ups that is far too prevalent” within the VA.

“How many times do we have to go down this road?” Let’s get beyond the bureaucracy and secrecy and restore veterans’ confidence in VA,” he said.