Florida: 79 Veterans Administration Patients Never Learned of Colonoscopy Risks

Department of Veterans Affairs officials identified but failed to notify 79 patients who should have been included last year when the VA informed more than 2,400 Miami-area patients that improperly cleaned equipment put them at risk for hepatitis B, hepatitis C, and HIV.

"This is inexcusable. We need to take care of these veterans," said Dr. Robert Jesse, the VA's principal deputy secretary for health.

Among the vets who were notified of their exposure after receiving a colonoscopy at the Miami VA Hospital, three later tested positive for HIV, seven for hepatitis C, and one for hepatitis B. There is no definitive link between these infections and the exposure at the VA, but hospital officials are providing testing, counseling, and medical care.

The current lapse stems from an administrative error, said VA officials. While an investigation is conducted -- expected to last up to 90 days -- Miami VA Healthcare System Director Mary Berrocal is being replaced with Thomas Capello, director of the Malcom Randall VA Medical Center in Gainesville.

The exposure in March 2009 was caused by an employee who did not sterilize some equipment as called for in the manufacturer's directions, but merely rinsed it. Ten employees were disciplined in the incident, Berrocal said.

Many of the 79 patients originally missed have been since notified, Jesse said, either by phone, or failing that, by letter. The VA has established a 24-hour, 7-day hotline for questions about the exposure: 877-575-8850.

Similar infection-control shortfalls occurred at VA hospitals in Murfreesboro, Tenn., and Augusta, Ga. In all, the problems at the three hospitals involved 11,000 veterans. Testing revealed three diagnoses of HIV, eight of hepatitis B, and 25 of hepatitis C.