1. They were not using a water irrigation tube with a check valve designed to prevent contaminated fluid from the patient from flowing back into the scope and irrigation water tubing.
2. The Auxiliary Water Tube (MAJ-855) had been altered with an incorrect connector.
In short, the Murfreesboro staff were not changing and reprocessing the MAJ-855 in accordance with set manufacturer protocol.

"Reprocessing procedures are defined by the endoscope manufacturer and generally involve careful cleaning of the entire external and internal surfaces with an appropriate cleaner, brushing any interior channels, and subjecting the entire scope to high level disinfection or sterilization as recommended in the manufacturer's instructions," reported William E. Duncan, M.D., Ph.D., MACP.
As a result of mishandling the manufacturer's protocol, a Patient Safety Alert (AL09-07) was issued to the entire VA system on December 22, 2008. The alert warned of using the correct valve and stressed the importance of following instructions given by manufacturers. Weeks later, 16 additional facilities reported they had in some way not reprocessed their endoscopes in accordance with manufacturers' instructions.

Finding the Solution

In response to the findings, the House Committee on Veterans' Affairs held the recent hearing and called for more centralized control of the veteran's health system.

John D. Daigh Jr., M.D., CPA, Assistant Inspector General for Healthcare Inspections, served as a witness in the hearing, commenting that VA medical facilities, in fact, have not complied with multiple directives to ensure endoscopes are properly reprocessed. Dr. Daigh reported, "unannounced OIG inspections last month found that medical facilities:
· Have the appropriate endoscope Standard Operating Procedures (SOPs) available 78 percent of the time.
· Have documented proper training of staff 50 percent of the time.
· Are compliant with both recommendations 43 percent of the time."

The meeting explored a number of steps to be taken by the VA to correct previous pitfalls experienced with the set up, use, reprocessing, and maintenance of reusable endoscopy equipment at VA medical facilities across the country.

Future directives include outlining the responsibility for reprocessing endoscopes as described in the VA Handbook "Supply, Processing, and Distribution (SPD) Operational Requirements" so that it is International Organization for Standardization (ISO) 9001 compliant. ISO is the world's largest developer and publisher of international standards, predominantly considered the standard for quality medical systems.

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