Saturday, April 18, 2009

Quality Nightmare is More than "Inadvertent Neglect"

The Veterans Administration exposed over 10,000 patients to other patients' blood and body fluids. The problem arose in cleaning endoscopic parts. The VA characterized the problems as:

"inadvertently neglecting to appropriately reprocess a specific auxiliary water tube."
Horse hockey! It's a quality nightmare. Over twenty five patients now have Hepatitis B, C, or AIDS.

When the VA system purchased the equipment from Olympus American Inc., the vendor should have trained hospital staff on proper cleaning. Did the Olympus trainer not cover the information adequately?

Olympus left maintenance and upkeep information with the hospital. Was the documentation clear as to what hospital staff needed to do to keep patients safe from exposure?

Was the water tube specified as a disposable or reusable device? If the VA wanted to save money, they might reuse a disposable item, especially if it could increase their incentive bonuses.

Three VA sites failed patients, Murfreesboro, TN, Augusta, GA and Miami, FL. How did incentive pay impact multi-site, multi-year periods of "inadvertent neglect"?

The AP obtained information on the exposure from the VA system. Their e-mail stated:

"tubing attached to the endoscopic equipment was cleaned at the end of each day, rather than immediately after each patient—a violation of the manufacturer's instructions."

The question is why? Why did the VA allow blood and body fluid exposure to over 10,000 patients? It's management's job to know.

"Inadvertent harm" is spin for management's failure to lead on quality. It belongs in the same place as Katrina's "unprecedented event." They both cover government nightmares for thousands of patients.

No comments: