Over 3,000 veterans who had routine tests at Miami’s VA Medical Center are thought to be at slight risk of infection from hepatitis or HIV because the hospital discovered that a section of tube used in water pumps for colonoscopies and other gastrointestinal procedures was only being rinsed and not disinfected.
A hospital announcement on Monday, reported in the Miami Herald and other local media, said officials have sent letters to over 2,500 veterans, and are still trying to trace another 700. 3,260 patients are thought to be at risk altogether.
John Vara, chief of staff of the Miami VA Health Care System, told the press that during an internal safety review they discovered on 4 March that a part of the equipment used in colonoscopies and other gastrointestinal procedures was not being disinfected, only rinsed. This was contrary to the manufacturer’s recommendation, he said.
It was an alert from the manufacturer that caused the hospital to carry out the safety review, reported the South Florida Sun Sentinel.
Vara said that a length of tube attached to a pump that is used with a type of endoscope was not being cleaned and disinfected, although the endoscope itself (the tube containing a fiber optic camera that goes inside the patient) was.
The risk comes from infection caused by the slight chance of backflow, although the pump itself does not come into contact with the patient.
Vara said there was no evidence that any of the patients had been infected, and although the risk of infection is low, he said “any risk is unacceptable”, reported the Miami Herald.
There have been other incidents recently of vets being put at risk of serious infection from incorrect hospital procedures, said the Herald.
In February about 6,400 vets at a VA center in Tennessee were told to get blood tests after equipment used in colonoscopies had not been handled properly, and another center in Augusta Georgia found that more than 1,800 vets were put at risk due to non-sterile use of ear, nose and throat instruments.
According to the South Florida Sun Sentinel, Vara said they don’t know why the manufacturer’s recommendations for disinfecting the tube were not followed.
A patient safety expert told the paper that the risk of exposure is likely to be very small and most patients were exposed a long time ago and are most likely out of danger.
However, another said it was still important to investigate how the error came about and make sure it doesn’t happen again. You don’t want to alarm people, but you need to know what went wrong and how to fix it, said Dr Anthony Silvagni, who chairs a safety group and is dean at the Nova Southeastern University health sciences division.
Democratic member for Miami of the US House of Representatives, Kendrick Meek, has written to Eric K Shinseki, Secretary of the Department of Veterans Affairs, and VA inspector general George Opfer, urging them to order an investigation, and he also wants a door to door campaign to alert all veterans who might be at risk.
In his letter to them Meek said it was “stomach-turning” that veterans have to face this situation and visit Special Care Clinics for blood tests, reported the Sentinel.
The VA have set up special care clinics in the Miami VA, the Broward County VA Clinic, the Homestead VA Clinic and the Key West VA Clinic to screen patients who may be infected.
Concerned patients may call the 24 hour Miami VA hotline on 305-575-7256 or toll free on 1-877-575-7256.