Hearing to air VA safety slip-ups

CHATTANOOGA, Tenn. — A congressional panel is pressing the Department of Veterans Affairs to disclose on Tuesday whether non-sterile equipment that may have exposed 10,000 veterans to HIV and other infections was isolated to three Southeast hospitals or is part of a wider problem.

"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 scheduled Tuesday's hearing in Washington to discuss mistakes involving endoscopic equipment used for colonoscopies and other procedures at its hospitals in Miami, Murfreesboro, Tenn., and Augusta, Ga. with top agency officials and to receive a yet-unreleased report by the VA's inspector general.

Roe said he had not yet seen the report but was told in a briefing Friday that the VA's inspector general conducted a random check on 42 VA locations.

VA officials have said problems discovered at more than a dozen other VA facilities did

not warrant follow-up blood tests for patients. 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.

The VA since February 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's chief patient safety officer, Dr. Jim Bagian, has said no one will ever know if the patients with HIV and hepatitis were infected because of improperly operated or cleaned endoscopic equipment used in colonoscopies at Murfreesboro and Miami — and to treat patients at the VA's ear, nose and throat clinic in Augusta. Bagian has also said all the mistakes were human error.

As of Friday, the VA reported that 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.

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. Since then, the VA says the problems have been discussed with staff at all VA hospitals and with representatives of the equipment manufacturer, Olympus American.