No slap on the hand will do after mishaps



Now, they must worry about their own safety while being treated at VA hospitals.

If that sounds extreme, consider that five patients have tested positive for HIV and 33 for hepatitis after being exposed to contaminated medical equipment at VA hospitals in Murfreesboro, Tenn., Miami and Augusta, Ga. Those 38 are among nearly 11,000 former service members who may have been exposed. Only 6,687 of that number had been notified of their test results as of May 1, according to the Department of Veterans Affairs.

These patients were at the hospital to receive colonoscopies or ear, nose and throat procedures. But the endoscopic equipment used in these procedures was not properly sterilized, exposing patients to body fluids of others.

The problem first cropped up in December at Alvin C. York VA Medical Center in Murfreesboro, where personnel were not following the manufacturer's recommended cleaning procedures for the equipment, The Associated Press has reported. That led to an internal alert in the VA hospital system, revealing problems in Augusta in January and Miami in March.

It's a terrifying scenario for these thousands of patients, and truly for hundreds of thousands more, who have heard repeated assurances by the VA of its health-care reliability in the face of criticism ranging from how it handled traumatized Vietnam vets to deplorable conditions at a facility for newly returned Iraq veterans during the Bush administration.

In the wake of the HIV and hepatitis cases, the VA has opened a hot line for veterans and their families and posted information on its Web site, but the trust of its patients may be irretrievable. These are not cases of unavoidable exposure, according to reports — standard hospital procedures were not followed. And the improper sterilizing practices went on for more than five years at the Murfreesboro and Miami hospitals, according to the VA — a long time to go without a review of procedures.

The hospitals in Murfreesboro, Miami and Augusta all use endoscopic equipment made by Olympus American Inc. That company has said in a statement that it is helping the VA address problems related to "inadvertently neglecting to appropriately reprocess a specific auxiliary water tube." It also has insisted that its cleaning procedures for its equipment are clear.

Neglect is a serious matter where such medical procedures are involved, which is why the VA's inspector general has begun an investigation, and members of Congress have called for a hearing later this month.

All too often, institutional mistakes result in drawn-out lawsuits, and eventually settlements and minor reprimands. That would not suffice this time. Veterans have done so much for this country that the VA must ensure that it fulfills its mission to take care of them in return. That means that anyone — at any level — found to have committed neglect that led to these exposures be punished for their misdeeds.

Maybe then, the VA can just begin a long path to restore trust.


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