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VA Addresses Problematic Results of Endoscopy Procedural Investigation

WASHINGTON, DC—The majority of VA facilities are up to code on colonoscopy reprocessing procedures, according to a recent investigation by the VA Office of the Inspector General. The investigation of 129 VA facilities was initiated after an unannounced inspection of 42 facilities in June revealed serious deficiencies in endoscopy procedures at those sites.

The June investigation showed that more than half of those 42 facilities did not have adequate SOPs in place, or proper documentation showing that the reprocessing staff was adequately trained. Substandard reprocessing practices triggered the investigation. These practices were discovered at 4 VA facilities last year and resulted in VA notifying over 10,000 veterans notified that they might have been exposed to infection. OIG recommended in June that VA leadership take steps to ensure compliance at all VA facilities.

During the most recent investigation, which took place August 3-6 at 129 reprocessing locations, OIG found that all 129 had adequate SOPs and proper documentation for its staff, save the White River Junction VA Medical Center in Vermont. There, the paperwork did not include enough detail about staff competence on certain equipment.

Despite the one error, which VA officials called a “typographical error,” VA is considering this a victory and validation of its safety efforts. “This report shows VA’s unparalleled quality assurance programs identified a risk and successfully corrected that risk on a national scale,” declared Gerald Cross, acting VA Under Secretary for Health, in a statement.

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