Healthcare Inspection Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities

The Secretary and VA’s Congressional oversight committees requested a review of the reprocessing of endoscopic equipment at several specific VA medical centers (VAMCs), and an assessment of the extent of related problems throughout the Veterans Health Administration (VHA). Our extensive review concluded that facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans. Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care. The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure. Nevertheless, we did conclude that the Clinical Risk Assessment Advisory Board has been an effective mechanism for providing guidance to VHA leadership on disclosure of adverse events to veterans. We recommended that VHA management ensure compliance with relevant directives regarding endoscope reprocessing, explore possibilities for improving the reliability of endoscope reprocessing with VA and non-VA experts, and review the VHA organizational structure and make necessary changes to implement quality controls and ensure compliance with directives.