Lawmakers on Tuesday blasted officials of the Department of Veterans Affairs after hearing testimony that the agency still wasn't following procedures for handling endoscopes, months after discovering that botched colonoscopies may have exposed veterans to hepatitis and HIV.
Endoscopes are used for checking the colon, nose and throat.
"I'm outraged that any of our nation's heroes were potentially infected or that they even have to worry about the possibility," said Rep. Harry Mitchell, D-Ariz., chairman of the Veterans Affairs subcommittee on oversight and investigations.
Investigators with the inspector general's office at the VA testified at Tuesday's subcommittee hearing that fewer than half of the VA medical center using endoscopes had standardized cleaning procedures and could show they properly trained their staffs for using the equipment. That finding was based on surprise inspections of 42 VA facilities in May.
The investigation came after the VA discovered in December 2008 and January of this year that endoscopes at VA facilities in Murfreesboro, Tenn.; Miami; and Augusta, Ga., were not maintained properly, possibly exposing veterans to the fluids of other patients.
In February, the VA began warning about 10,000 former patients — some who had colonoscopies and other endoscopic procedures as far back as 2003 — that they may have been exposed to HIV and hepatitis infections.
The agency said that six veterans who took the follow-up blood checks tested positive for HIV, 34 tested positive for hepatitis C and 13 tested positive for hepatitis B. There is no way to prove whether the infections came from VA procedures
Mitchell said he plans to ask the inspector general's office to repeat its surprise inspections within 90 days.
Agency officials apologized Tuesday for the continued weaknesses and told lawmakers that they would do better. Veterans Affairs Secretary Eric Shinseki said he was taking disciplinary action.
John Daigh, the VA's assistant inspector general who led the review, said the findings "troubled me greatly."
"We think there are systemic issues," Daigh said.
Lawmakers expressed disbelief that medical centers didn't immediately tighten procedures after the safety alert.
"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 and yet this investigation shows that many, many did not," said House Veterans Affairs Committee Chairman Bob Filner, D-Calif., who praised the VA for being transparent about the mistakes. "There will be a public accounting of this situation."
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 disciplinary measures, he said he would require each medical center director to verify in writing that they are complying with agency guidelines.
The VA said the problems were caused by human error in the cleaning and operation of endoscopic equipment.
At the Murfreesboro facility, for example, officials believe medical staff mistakenly used a two-way valve that may have allowed bodily fluids to enter a part of the scope that was believed to be sterile.
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. "My sense is that there are some greater problems out there."
Contributing: Bill Theobald in Washington, D.C.; Associated Press