VA Continues Endoscopic Procedure Notification for Veterans

On December 1, 2008, VA’s Tennessee Health Care System*, located in Murfreesboro, TN, identified a problem related to the reprocessing of endoscopy equipment. Following a review of the issue, VA notified patients to get tested for possible infections that have a low risk of occurring as a result of these improper processing procedures.
   *small low risk event at Mountain Home, TN has revealed no positive tests

In December and January, all VA facilities were required to review their processes to ensure they are in compliance with the manufacturer’s instructions. These reviews identified significant reprocessing issues at the Augusta VA Medical Center and at the Miami VA Medical Center, which also requiring patient notifications and testing.

Patients who may have been exposed to cross contamination were patients that received endoscopic procedures at the:

• Murfreesboro GI Clinic from April 2003 to December 2008;
• Augusta ENT Clinic from January 2008 to November 2008; or
• Miami GI Clinic from May 2004 to March 2009 

These are not necessarily linked to any endoscopy issues and the evaluation continues. We are continuing to notify individuals whose letters have been returned as undeliverable, and working with homeless coordinators to reach veterans with no known home address.

VA’s Foremost Concern is the Safety of Patients

As part of the Department’s commitment to reducing and preventing inadvertent harm to patients, over 100 VA personnel at Murfreesboro, TN; Augusta, GA; and Miami, FL hospitals have been assigned to ensure that affected Veterans receive prompt testing and appropriate counseling. This page reflects the most current notifications, testing, and results, and will be updated when new information is available.

The Department is a leader in the health care industry in developing and nurturing a culture of safety at all its facilities. Patient safety managers at all 153 VA hospitals are leading efforts to reduce and eliminate harm. Although the risk of cross contamination and exposure to these infections is exceptionally low, our directive is to treat all Veterans potentially affected, regardless of risk, and regardless of cause.

Health Care "Safety Step-up"

From March 8-14, 2009 VA implemented a Safety Step-up at all 153 hospitals and 731 community-based outpatient clinics across the nation. Patient appointments were not affected. After issues with proper sterilization of endoscopic equipment required infection-risk notices at four different medical centers since December 2008, VA instituted immediate alerts to all of its facilities to ensure patient safety. The nationwide Step-Up was the culmination of an education and safeguard program VA developed to implement stronger standard operating procedures and accountability practices at facilities where VA provides care. This process is the model for ethical and transparent self identification, notification, and treatment of patients.

Contact Us

If you believe you may be affected or need additional information, please call the Special Care Call center at 1-877-575-7256 (available, 24 hours a day, seven days a week) or e-mail us at Endoscopy Inquiry. When submitting e-mail inquiries, please reference the facility you are inquiring about and annotate if you are a member of the press.