Officials in Washington promise a full investigation and disciplinary action after they admitted that more than 1,800 veterans in the St. Louis area were put at risk for HIV and other diseases from dental tools that had not been properly cleaned between patients.
The 1,812 veterans who received dental care at the St. Louis VA Medical Center at the John Cochran Division between Februrary 2009 and March 11, 2010, were sent letters this week, telling them of the sanitation mistake and offering free testing for HIV, hepatitis B and hepatitis C.
The state's federal lawmakers were furious that Missouri's veterans were exposed to such a serious threat for such a long time.
"This isn't just one person who didn't do their job right," U.S. Rep. Todd Akin, R-Mo., told ABCNews.com today. "Certainly this is an outrageous situation that's occurred and been allowed to occur over a period of time."
According to an information sheet released to veterans from the VA Medical Center, the center was found -- during a routine, unnanncouned visit -- to have failed to clean dental handpieces with a specialized detergent before they were sterilized.
"VA officials acknowledge there were missed opportunities to uncover the problem sooner," the notice read.
According to a timeline provided by the VA, the discovery was made in early March. Dentistry services were suspended for about three weeks while officials investigated and ordered the retraining of staff, along with a redesign of the procedure for cleaning dental equipment.
Akin was one of several angry lawmakers who sent letters to U.S. Department of Veterans Affairs Secretary Eric Shinseki.
In his letter, Akin blasted the St. Louis VA Medical Center's response for the failure that "a growing number of veterans have been utilizing dental services and that the organization simply got 'too busy.'"
In the June 29 letter, Akin noted that a similar error of this magnitude in the private sector would lead to the discipline and even dismissal of those deemed responsible.
"I trust that the staff and management of John Cochran are held to no less a standard," he wrote.
U.S. Rep. Russ Carnahan, D-Mo., similarly blasted the VA Medical Center.
"This is absolutely unacceptable," Carnahan said in a statement this week. "No veteran who has served and risked their life for this great nation should have to worry about their personal safety when receiving much needed health care services from a Veterans Administration hospital."
In a statement released by the Department of U.S. Veterans Affairs, Shinseki called the nearly year-long failure "unacceptable" and vowed that this facility, like others around the country, would be transparent in its accounting for mistakes.
"VA is committed to ensuring that all our health care facilities are safe," Shinseki said in the statement. "VA will continue to investigate the actions of individuals involved, and the proper administrative and disciplinary measures will be taken."
In its letter to veterans, the VA said the risk of exposure to any disease from dental tools was "very low."
But Akin wondered what other medical failings might have occurred at John Cochran.
"If you've got that kind of a systems problem in one area, it suggests there are probably other things that need to be looked at as well."
As the war drags on, incidents of mismanagement and substandard care have become a problem for the Department of Veterans Affairs. Walter Reed Army Medical Center came under fire in 2007 after a series of reports showed numerous failings in the quality of care for injured soldiers and veterans.
A swift effort was promised to fix problems there and at other facilities across the country.