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Dirty and broken surgical tools, holes in wrappers documented at Cincy VA
They are problems one hopes never to find in an operating room. Problems including bone contaminated drill bits, broken or rusty surgical instruments, holes in sterile wrappers and a needle holder that arrived with a used needle still in it.
Yet these and many other events were documented hundreds of times at the Cincinnati Veterans Affairs Medical Center, according to records obtained by the Scripps News Washington Bureau and WCPO.
They known as “quality events” and “non conforming products” in the VA system. And they were reported in 16.27 percent of surgeries at the Cincinnati VA in its 2015 fiscal year, according to an internal document.
That at least 581 problems in 3,571 surgeries, or one in every six operations during that period, numbers Scripps/WCPO verified through multiple sources and internal documents.
The VA has yet to release a final report on an inquiry into problems inside the Cincinnati hospital, including concerns about sterilization. But hospital administrators have been telling employees and members of Congress that contaminated medical equipment is not an issue in Cincinnati.
That led to a dramatic exchange at an April 13 Veterans Town Hall event, presented by Scripps and WCPO at a VFW post in Sharonville.
“I just now understand that the investigations show there was no bone and nothing was wrong with the instruments,” VA Nurse Technician Scott Landrum, who said he personally witnessed some of these incidents, told the Town Hall audience that night. “I the person who found the instruments and what was wrong with them. How in the world can they say that? I the person who filled out the report. Where did those reports go?”
a Patient Safety Standpoint, it Abhorrent a recurring theme among Cincinnati VA whistleblowers, a group of more than three dozen current and former employees who voiced concerns to Scripps and WCPO after they felt ignored by their VA bosses.
Their concerns included faulty sterilization procedures and incorrect or potentially unsterile surgical equipment.
“I filed between 10 and 12 of these incident reports, and I never heard back about a single one,” said Dr. Jonathon Wolf, an orthopedic surgeon who said he worked periodically during his residency at the Cincinnati VA between 2009 and 2014, including a stint as chief resident.
Dr. Jonathon Wolf is an orthopedic surgeon who worked periodically at the Cincinnati VA between 2009 and 2014. Here, he talks about his experiences at the Cincinnati VA. 25 press release that its investigators “did not substantiate” allegations involving “quality of care for veterans.”
On that same day, Cincinnati VA records show at least five quality events, including a dental clinic incident in which a drilling tool showed up in a sealed package marked “Dirty.”
On May 20, new Cincinnati Medical Center Director Glenn Costie congratulated the hospital Sterile Processing Service on “great reviews” by VA administrators who found “no patient safety or quality finding” in a “normal annual visit,” according to an email Scripps and WCPO obtained.
“Well, that typical VA,” said Rep. Jeff Miller, a Republican from Florida and chairman of the House Committee on Veterans Affairs. “They investigate themselves. They clear themselves. And they say, to see here. We gonna move along. Cincinnati VA did not respond to multiple interview requests, but answered questions in writing, defending its record on patient safety.
“We have had 12 external reviews so far this year and we are proud of the fact that all have acknowledged the high level of quality here,” the hospital said.
is Not Reporting All Issues Cincinnati VA would not release internal records on quality problems, but whistleblowers did.
Internal reports obtained by Scripps and WCPO show a three year pattern of operating room mishaps.
Among the problems:
A “retained foreign body” in the eye of a 79 year old Korean War veteran in July 2013. A 2013 report to a VA review panel said a “strand” was found in the veteran eye following cataract surgery. A report on the incident said doctors removed a “long white fibrous strand” from the veteran eye. After “conversations with multiple staff members,” it was determined that the fiber likely came from a surgical tool with a silicone tip, “which becomes increasingly sticky with each reprocessing and thus more likely to attract fibers that can only be seen under the microscope.” The report indicates the Cincinnati VA was ordered to halt the practice of reusing those tools after the July incident.
Individual descriptions of quality problems documented at least 11 cases of “bioburden” in the 12 months that ended Jan. 4, 2016, including two events on the same day in November. A VA policy memorandum defines bioburden as “organic material” such as blood, bone and other bodily debris that “must be eliminated before effective sterilization can take place.”
The two problems on Nov. 9 included a dental kit that resulted in a five minute delay: “Scaler has debris left on it!” A second problem on Nov. 9 involved equipment prepared for shoulder replacement surgery: “Suspected bone inside cannulated glenoid drill bit.”
Throughout the second half of 2015, VA staffers documented problems with the underreporting of incidents and the computer system used to report them, “making reporting inaccurate,” according to meeting minutes for the Operative and Invasive Procedures Committee at the Cincinnati VA. “The committee believes staff is not reporting all issues.”
The same committee documented an increase in problems in the first two months of 2016. The committee tracks the problems as a percentage of all surgical cases. It increased from 6.77 percent in January to 11.21 percent in February.
The Cincinnati VA said it uses a computer system called Censitrac to ensure “issues are caught before surgical instruments ever reach the veteran. We exceed the community standard which reports only major issues.”
Something Out, You Become the Problem Brad Wenstrup, a Republican from Cincinnati, has twice raised concerns about dirty surgical tools at the Cincinnati VA.
In September 2013, he inquired about delayed and canceled surgeries after a constituent contacted him.
Internal records show hospital officials reviewed 58 cases between July 1 and Sept. 4 in response to Wenstrup inquiry. They confirmed two surgeries that were canceled “because equipment and supplies were not ready” and five cases that were delayed because of “issues surrounding the reprocessing” of surgical instruments.