In response to allegations of endoscope reprocessing problems (possible contamination of three gastrointestinal endoscopes identified before patient use) at the St. Louis VA Medical Center, the VA Office of Inspector General, Office of Healthcare Inspections, conducted an investigation. Below is the Executive Summary. For the complete report, go to: www4.va.gov
Executive Summary
The VA Office of Inspector General, Office of Healthcare Inspections, conducted an inspection to determine the validity of allegations regarding ongoing issues in the Supply, Processing and Distribution (SPD) Department related to endoscope reprocessing and communication at the St. Louis VA Medical Center, St. Louis, Missouri. A complainant alleged that endoscope reprocessing issues have been ongoing. It was further alleged that there were breakdowns in communications with regard to adverse events and outcomes.
We substantiated the allegation that endoscope reprocessing issues have been ongoing. We reviewed documentation related to three contaminated gastrointestinal (GI) endoscopes which were identified prior to patient use. We also reviewed documents notifying managers that damage and repairs to endoscopes had increased. We requested the 2009 repair log and associated costs from SPD and found that a majority of the scopes that were damaged or needed repair belonged to the GI service.
We substantiated the allegation of breakdowns in communication of adverse events and outcomes. We found minimal documentation as well as communication failures for two of the three adverse event reports (AER) reviewed.
In addition, we conducted an unannounced inspection of the SPD area. We identified several items related to reusable medical equipment reprocessing and staff safety that needed improvement as required by VHA policies.
We recommended that the AER reporting process is clearly defined, timely, and well-documented and that implemented action plans are monitored for compliance to eliminate ongoing endoscopes damage and reprocessing issues. We also recommended that SPD meets VHA policy and is monitored for compliance.
The VISV and Medical Center Directors agreed with the findings and recommendations. The implementation plans are acceptable, and we will follow up on the planned actions until they are completed.