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Federal agency cites Buffalo VA’s violation of sterilization procedure standards

WASHINGTON – Employees at the Buffalo VA Medical Center have violated safety standards for sterilizing medical equipment, the federal agency charged with investigating whistle-blower complaints said Monday.

The Office of Special Counsel cited the problems at the Buffalo facility in a letter to President Obama in which it said that at health facilities nationwide, the VA often admits to deficiencies in its patient care while implausibly denying that those problems affect veterans’ health.

For example, in Buffalo, the VA’s Office of the Medical Inspector “substantiated a whistle-blower’s allegation that health care professionals do not always comply with VA sterilization standards for wearing personal protective equipment and that these workers occasionally failed to place indicator strips in surgical trays and mislabeled sterile instruments,” the letter to the president said.

Yet while acknowledging those problems, “OMI did not believe that the confirmed allegations affected patient safety,” Special Counsel Carolyn M. Lerner wrote.

Evangeline Conley, a spokeswoman for the VA Western NY Healthcare System, said in a statement that the VA’s Office of the Medical Inspector did not find violations or apparent violations of any laws, mandatory rules or regulations.

However, after concerns arose, “a review was requested by leadership from outside Sterilization Processing Service experts to improve processes and systems,” Conley added.

A spokesman at Lerner’s office confirmed that it received a whistle-blower complaint about sterilization procedures at the Buffalo hospital in late 2013 but refused to provide further details, saying its inquiry into the matter is continuing.

The Office of Special Counsel also refused to comment on internal VA emails and another document that appears to detail the concerns about sterilization procedures at the Buffalo VA or to say whether those emails and that document led to its investigation.

A Sept. 4, 2013, email to hospital employees from Larry McCurdy, chief of sterile processing service at the Buffalo VA, said the sterilization problem at the facility “is getting out of control,” with employees not labeling medical instruments or counting them correctly.

McCurdy followed that up with an Oct. 22 email in which he complained about procedures in the hospital’s catheterization laboratory, where some instruments were found to be dirty, with two sets of them containing blood.

“This is the last day that the Cath Lab or any place else will receive dirty instruments from people not inspecting sets, any farther instances of this will be handled as a behavior issue not as a performance issue, or you not knowing jobs, I am convinced that everyone here knows their job, so do your jobs,” McCurdy wrote in the email, which, like the Sept. 4 email, was first reported earlier this month by the Brenner Brief, a conservative blog.

The Brenner Brief also cited an internal VA “Report of Contact” dated March 5 of this year, in which a Buffalo VA employee wrote: “As I was setting up my scopes for the day I noticed one of the suction buttons had dried fecal matter wedged inside the neck of the button. The packaging was sealed, it came up from sterile processing that way.”

Those recent complaints about sterilization procedures at the Buffalo VA come only 17 months after the hospital acknowledged that it inadvertently had been reusing insulin pens on multiple patients between Oct. 19, 2010, and Nov. 1, 2012, thereby possibly exposing 716 veterans to HIV or hepatitis.

Rep. Chris Collins, R-Clarence, said it was disappointing that such problems appear to be recurring at the Buffalo VA.

“It’s clear that just as it was two years ago up to right now, they don’t really have a focus on quality,” Collins said. “Our veterans deserve better. I would wager that their policies and procedures are not what they should be.”

If so, that would mean that the problems at the Buffalo hospital might be occurring elsewhere as well, Collins said. And in her letter to Obama, Lerner, the special counsel, cited Buffalo among 10 examples where the VA acknowledged deficiencies in its health care while denying that those problems really affected veterans in any way.

“The VA, and particularly the VA’s Office of the Medical Inspector, has consistently used a ‘harmless error’ defense, where the department acknowledges problems but claims patient care is unaffected,” Lerner said.

“This approach has prevented the VA from acknowledging the severity of systemic problems and from taking the necessary steps to provide quality care to veterans. As a result, veterans’ health and safety has been unnecessarily put at risk.”

Rep. Brian Higgins, a Buffalo Democrat whose district includes the hospital, said he plans to address the latest revelations about the Buffalo VA with both acting VA Secretary Sloan Gibson and the Office of Special Counsel. He said it’s simply unbelievable that the problems that have surfaced there would have no impact on veterans’ health.

“These are not harmless errors,” Higgins said. “They have the potential to do harm.”

In the VA’s statement on the issue, Conley offered no specifics on the extent of the sterilization problems but said the hospital takes any whistle-blower complaint seriously.

“We cooperate with the Office of Special Counsel, the Inspector General or any other investigative agency to understand what happened, prevent similar incidents in the future, hold those responsible accountable consistent with due process under the law and share lessons learned across VA’s system,” she said.

In his emails about the sterilization problem, McCurdy appeared to take the sterilization issue seriously. But ironically, both of his messages to hospital employees were rife with grammatical, syntax and spelling errors.

“Label sets and item correctly it is causing pataient to be exposed to ansthesia,” he wrote Sept. 4.

“Today there was several instrument sets opened in the Cath Lab that was dirty, upon examine of the sets 2 of them contained blood, the first part of assembly of a set is inspection of instrumentation before putting it in the tray, this step was obvious missed on f few occasions, all is to be manual cleaned prior to putting the in the ultrasonic or automatic washer and inspected for cleanliness as well as proper functionality the first place this should be done is in decontamination, and finally in Prep during the assembly process,” McCurdy wrote Oct. 22.

Seeing that, Collins said the sloppiness of McCurdy’s emails, and their lack of an urgent tone, sent hospital employees the wrong message.

“If he worked for me, I’d fire him this afternoon,” Collins said of McCurdy.