U.S. Department of Veterans Affairs medical centers continue to fall short in the area of endoscopic safety, even after reprocessing errors led 3 of the facilities to warn more than 10,000 patients earlier this year that they may have been exposed to hepatitis B and C and HIV, according to a new report.

Unannounced inspections conducted last month at 42 randomly selected centers and the 3 at issue found that 78% had appropriate standard operating procedures for endoscopy available, 50% had documented the proper training of staff and only 43% were compliant on both counts, said John D. Daigh Jr., MD, CPA, the VA’s assistant inspector general for healthcare inspections.

"I believe that VA provides high quality health care to veterans," he told a House of Representatives subcommittee on veterans’ affairs June 16, the day the report was released. "However, I am concerned that the controls are not in place to ensure the delivery of a uniform, high quality medical benefit."

While Dr. Daigh noted that VA healthcare leadership had effectively notified potentially affected parties of the reprocessing errors, the inspection findings "led to the conclusion that serious management issues need to be addressed by VA with respect to the management of industrial processes such as the reprocessing of endoscopes." His office recommended that the agency’s healthcare authorities "ensure compliance with relevant directives regarding endoscope reprocessing," "explore possibilities for improving the reliability of endoscope reprocessing with VA and non-VA experts," and "make the necessary changes to implement quality controls and ensure compliance with directives."

Of the VA patients who underwent testing after the notification was issued, 6 tested positive for HIV, 13 for hepatitis B and 34 for hepatitis C, according to a published report, although experts are uncertain on whether the infections originated from the reprocessing errors.

—David Bernard