More war veterans at risk of HIV (& Hepatitis)infection after VA hospital error

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More war veterans at risk of HIV infection after VA hospital error

By Fred Tasker

The Miami Herald

Updated: 9:47 a.m. Friday, Feb. 11, 2011

Posted: 9:46 a.m. Friday, Feb. 11, 2011

The Veterans Administration said Tuesday it has found another 12 South Florida

veterans who never were notified they might have received colonoscopies with

improperly cleaned equipment at the Miami VA hospital as far back as 2004. It’s

the third such notification, totaling nearly 2,500 veterans.

The VA, which last year said it had taken extensive steps to prevent another

such notification error, again blamed the way in which the hospital keeps

medical records.

VA officials said this error was discovered when the Miami U.S. Attorney’s

Office, gathering information related to veterans who have filed lawsuits in the

matter, asked the Miami VA hospital to recheck its records. While the VA

hospital has electronic medical records, it said the errors were found by

checking supplemental paper log books.

It wasn’t clear why the 12 new names would be on paper but not electronic

records. Notification to the 12 veterans began Tuesday; by late afternoon all

but three had been reached, a spokeswoman said.

VA spokeswoman Kay Hollingsworth said no disciplinary action is anticipated

in the new finding.

In March 2009 the VA wrote to more than 2,400 local veterans saying that

colonoscopies they had received since 2004 might have been done with equipment

that was rinsed instead of chemically sterilized as noted under manufacturer’s

requirements. Similar problems were found in VA facilities in Augusta, Ga., and

Murfreesboro, Tenn., involving more than 11,000 veterans.

Colonoscopies in Miami were temporarily suspended. Tests found three local

veterans were HIV positive, seven had hepatitis C and one had hepatitis B. VA

officials said there was no way to know whether the vets acquired the infections

from the colonoscopies.

In July 2010, the VA announced it had identified an additional 79 South Florida

veterans not included in the 2009 notification due to errors in record keeping.

It quickly notified most of those vets. A new VA investigation was initiated,

and Miami VA administrator Berrocal was temporarily reassigned.

That October, Berrocal was reinstated without public notice. Results of the new

investigation were not announced. A Freedom of Information request filed by The

Miami Herald for results of that investigation has not yet been filled.

U.S. Rep. Ileana Ros-Lehtinen, R-Miami, called the new announcement “beyond

outrageous. Our veterans deserve better than this, plain and simple.” She said

she will seek to lead a bipartisan South Florida congressional delegation to the

Miami VA to look into the matter.

Hollingsworth, the VA spokeswoman, said the log books that identified the 12 new

veterans were not reviewed as part of the original 2009 investigation because

they were “an incomplete source of information.” It wasn’t until the U.S.

Attorney’s Office request that the 17,848 paper files were checked and the

errors found.

Paper files are kept for issues such as tracking workloads, training or ensuring

biopsy follow-ups, Hollingsworth said.

A spokeswoman for the Miami U.S. Attorney’s Office declined to comment on any

veteran lawsuits that may have been filed.

Nevin Weaver, director for the VA Sunshine Healthcare Network, said a

comprehensive new plan is being put in place to prevent such recurrences.

“This latest review reflects the VA’s absolute, on-going commitment to taking

all measures possible to ensure their patients receive the very best medical

care,” he said