Recently, more than 500 veterans in upstate New York received some dire news that could be classified as tragic irony: After they survived wars and occupations overseas, the very health system that was meant to protect them at home — the United States Department of Veterans Affairs (VA) — could ultimately end up being the very thing that kills them.
Those veterans were potentially exposed to hepatitis, HIV and more after improperly cleaned endoscopes were inserted into their bodies by an employee of the Buffalo VA.
How one overlooked this basic commonsense procedure of medical care is beyond me, especially since this is not the first such failure to plague the VA and its patients.
In early 2009, the VA launched an internal investigation to figure out how it was possible that 10,000 patients from VA hospitals in three states (Florida, Georgia, and Tennessee) were put at risk after unsterilized colonoscopy equipment was repeatedly used. After checking every one of those individuals exposed to the dirty tubes, it was found that 16 of them were infected -- 10 with hepatitis and six with “unspecified viral infections”.
This wasn’t the Buffalo VA’s first major scare, either.
In 2013, more than 700 vets who were served by the medical center could have been exposed to HIV or hepatitis from resued insulin pens. Hospital staff did not follow protocol (and some people believe that necessary protocol didn’t even exist at the VA) and failed to, one, dispose of the one-time use pens, and, two, label the pens by individual patient if the incorrect assumption did exist that they were intended to be used more than once. A routine inspection brought this despicable behavior to light, discovering the unlabeled, previously used pens in supply carts ready to be used again.
What makes these incidents (three of many) so disconcerting is that the VA never learned from its mistakes. As a matter of fact, mistakes don’t even represent a catalyst for change within the organization. That was made evident during the 2009 HIV scare when, three months after the initial announcement of the colonoscopy nightmare, the VA discovered that half of their medical centers still had not developed standardized cleaning procedures, nor could they show that they properly trained their staff on using the equipment. If the thought of infecting a patient — or the liability that comes with it — wasn’t enough to facilitate change, then what would be?
That’s the difference between the VA and private sector care. In the world of private medicine, one HIV scare is more than enough. It would have set off an immediate domino effect by which capable and accountable people would have initiated the necessary changes to policy and procedure, not only with the failed practice in question, but also with a myriad of practices and equipment that could potentially create similar risk. Whereas the private sector reacts immediately and with purpose, the public sector moves at a snail’s pace, if even at all.
Furthermore, had any of these HIV scares occurred in regular hospitals, heads would have rolled. Workers from nurses all the way to upper management would have suffered the consequences and the clinics would have seen a necessary housecleaning that would have ultimately led to better-managed hospitals and better-served clientele. Failure to do so would lead to fewer patients and, more than likely, a loss of licenses for workers and organizations alike.
That didn’t happen in the VA. No one in a position of responsibility lost their job because of the 2009 incidents that mirror the most recent Buffalo incident; as a matter of fact, the head of the failed Miami VA clinic was only re-assigned. It also appears that no one is in the crosshairs for the 2013 or 2017 Buffalo debacles.
Accountability of “leadership” doesn’t exist in the VA.
That’s unfortunate on many levels.
For starters, no one enjoys working for unaccountable leaders. I know quite a few people who either interned or worked at VA hospitals. Most of them decided not to choose careers at the VA.
More importantly, no one wants to be served by unaccountable organizations. If these horror stories are any gauge of the care that veterans could receive at VAs, they run the risk of infection and premature death at the hands of a federal agency that allegedly has their best interests in mind.
Our vets gave so much and saw so much in combat. They did that for all of us. Because of those sacrifices the American Way they deserve far better attention than what we are giving them now. It’s time to reform the VA and veterans’ care in general. It’s the least that America can do for our heroes.
From the 27 August 2017 Greater Niagara Newspapers