Snowe, Collins Call on VA to Evaluate Surgical Practices and Standards

SNOWE, COLLINS CALL ON VA TO EVALUATE SURGICAL PRACTICES AND STANDARDS

Veterans Who Could be at Risk to Receive Free Testing

Today, Maine Senators Olympia J. Snowe and Susan Collins called on the Department of Veterans' Affairs to evaluate surgical practices and standards after it was revealed that lapses in proper sterilization procedures had occurred at some medical centers, including Togus. The Senators sent a letter to Department of Veterans Affairs Secretary R. James Nicholson urging him to undertake a comprehensive review of equipment sterilization practices to minimize the possibility of similar problems occurring again within the VA medical system. While acknowledging shortcomings at Togus, Snowe and Collins also praised the good professional practices of the employees at the Togus facility that brought the inadequate sterilization procedures to light.

"First and foremost, we must always strive to ensure that our veterans receive the safe, high-quality medical care they deserve," said Snowe and Collins. "The VA has assured us that veterans in Maine who may have been put at risk by inadequate sterilization procedures at Togus will be notified and receive follow-up testing at no cost and at the nearest VA facility. We urge the VA to take the next step and launch a thorough investigation into sterilization practices at all its facilities to prevent this from happening again. Although the sterilization problems at Togus are serious and should not have happened in the first place, we are deeply appreciative of the professionalism demonstrated by Togus employees to discover and report the inadequate sterilization procedures. As a result of their reporting, VA medical centers across the system, the Veteran's Health Administration and the manufacturer now have the opportunity to correct these procedures so that veterans can be assured that the equipment and procedure is safer than it was."

In Maine 509 veterans have been identified as being at risk, and the notification process is ongoing. All of them will receive testing for Hepatitis B, Hepatitis C and HIV at no cost. Testing will occur in nearest VA facility so that veterans will not be forced to travel all the way to Togus.

Following is the full text of the letter:

The Honorable R. James Nicholson

Secretary

Department of Veterans' Affairs

810 Vermont Avenue, NW

Washington, D.C. 20420

Dear Mr. Secretary,

We are writing in regard to the recent disclosure that the Veterans Health Administration has learned that an instrument used in many VA medical facilities, including the Togus VA Medical Center, was not being disinfected properly prior to use in prostate biopsy procedures. We believe that the safety of a veteran must be paramount when undergoing medical procedures or receiving medical care as a patient within the VA medical system. We see many reasons for concern as a result of this lapse but we also see marked improvements in the processes within the VA for handling the discovery of such a patient safety problem.

First, let us say we are deeply appreciative that the good professional practices of the employees at the Togus facility brought the inadequate sterilization procedures to light. As a result of their reporting, VA medical centers across the system, the Veteran's Health Administration and the manufacturer now have the opportunity to correct these procedures so that veterans can be assured that safety in the use of this equipment in performing procedures is never compromised. Clearly, as demonstrated by this example, such an environment and culture that fosters prompt identification and reporting of such safety problems is critical. Otherwise, personnel might fail to report safety problems due to fear of possible retribution, and that would ill-serve the health of our veterans.

We encourage the VA health system to inform the wider public and private health systems about the identification of inadequate sterilization that stems, in part, from the manufacturer's recommended procedures, in order to ensure patients being treated in other health care institutions nationwide are protected during the use of this equipment. While we believe the VA is responding responsibly to correct these lapses and to inform all veterans who may have received a biopsy with a device that may not have been properly sterilized, we urge the VA to undertake a comprehensive review of equipment sterilization practices to minimize the possibility of such problems occurring with other invasive instruments used within the VA medical system.

In addition, it is known that this equipment is also used in VA medical centers that were not among the 16 identified as requiring clarified procedures. Because all centers using the equipment would have access to the same manuals, this raises a question of standardized practices across the system. We ask that you provide us with your plan to ensure that sterilization practices are standardized and applied consistently throughout the system.

Finally, we understand that the VA is currently notifying the 509 veterans in Maine identified as being at risk to offer them no-cost testing for Hepatitis B, Hepatitis C and HIV infection. Because of the vast distances some veterans must travel to get to Togus VA Medical Center, we ask that veterans be allowed to receive such testing at the nearest veterans medical care facility to minimize the burden on the veteran and to receive appropriate travel reimbursement for those veterans who many not be in close proximity to a VA facility.

Mr. Secretary, we thank you for the forthright manner with which this issue has been handled by the VA and look forward to working with you to making the VA medical system even safer and more effective for our veterans.

http://snowe.senate.gov/news.htm