Infection control concerns are not unique to outpatient surgery centers.

Case in point: Issued in a report by the Veterans Affairs Office of Inspector General (VAOIG) on March 16, 2010, the Veterans Health Administration (VHA) concluded that the risk of healthcare-acquired infections associated with several recently confirmed infection-control errors, or breaches, within the Veterans Affairs Caribbean Healthcare System (VACHS) – which includes a Veterans Affairs medical center (VAMC) in San Juan (Puerto Rico) – posed a “negligible” risk of infection not warranting patient notification. (To read the VAOIG’s report, visit: )

An evaluation of the VHA’s assessment of risk suggests that the VHA’s conclusions are in error and more assuaging and forbearing than sound and consistent. The medical literature suggests that these breaches would pose an increased (not negligible) risk of infection warranting their disclosure to veterans. (My complete evaluation of the VHA’s assessment of risk can be found on-line at: ).

These infection-control breaches are several and include the following: (a) failure to disinfect transvaginal ultrasound transducers after each use; (b) improper cleaning of flexible laryngoscopes after each use; (c) failure to leak-test flexible endoscopes; and (d) the (routine) use of a damaged (and misbranded) flexible endoscope. Apparently overlooked by the VHA, each of these breaches identified within the VACHS has been linked either directly to patient injury or, at the very least, poses an increased risk of transmission of such infectious agents as HIV and the hepatitis B and C viruses.

Briefly, one study reports that transvaginal (and transrectal) ultrasound transducers, including those covered with a “protective” sheath, were contaminated after use with infectious microorganisms, including the human papilloma virus (HPV), which has been linked to cervical and anogenital cancers. Other studies similarly report that flexible (and rigid) laryngoscopes may become contaminated with and transmit blood and other potentially infectious materials if not properly cleaned and disinfected after each use. And another study reports the patient-to-patient transmission of respiratory tuberculosis due to the use of a damaged flexible endoscope that had not been leak tested.

As if a case of déjà vu, these breaches identified within the VACHS are markedly similar in type and detail to several that the VAOIG substantiated one year earlier at three VAMCs located in Murfreesboro (TN), Augusta (GA), and Miami (FL) – findings that suggest not only that “fundamental defects” identified by the VHA itself within its own structure remain intact, but also that VHA’s commitment to public health is lacking. (These breaches were the focus of congressional hearings in 2009.)

But, whereas it concluded that the risk of infection associated with the improper cleaning and disinfection of flexible laryngoscopes at the VAMC in Augusta (GA) posed a sufficiently significant risk to warrant the notification of 1069 patients, the VHA paradoxically, if inexplicably, concluded that this same breach identified one year later at the VAMC in San Juan posed a negligible risk. Such incongruous risk assessments by the VHA are a problematic contrariety apparently at odds with, among others, the Department of Veterans Affairs (VA) policies not only requiring a consistent standard of care vis-à-vis the control and prevention of infectious diseases but also regarding patient disclosure – policies that emphasize the VHA’s “ethical,” “legal” and “presumptive obligation” to inform patients of “harmful or potentially harmful” adverse events, even those that “may not be obvious or severe.”

As confusing as this contrariety is the VHA’s rationale for notifying (in 2008) more than 6000 patients of the VAMC in Murfreesboro of the potential risk of infection associated with the improper use and cleaning of irrigation tubing used during colonoscopy, despite this breach (to date) having not been linked to infection, while, in contrast, not notifying patients within the VACHS of an apparently more hazardous breach, one that has been directly linked to infection: the routine use of a damaged flexible endoscope.

In conclusion, these findings and reports suggest, in addition to some of the VHA’s assessments of risk being unreliable and inconsistent and the VHA vis-a-vis infection control still in disrepair, that a re-assessment by the VHA of the risk of infection associated with the aforementioned breaches identified within the VACHS is necessary because, in the words of the VHA itself, the improper disinfection of reusable medical equipment “places veterans at risk of infection.”