This week the Department of Veterans Affairs mailed thousands of letters to military veterans warning that they may have been exposed to the bodily fluids of other patients at a VA clinic in Murfreesboro, Tenn.
Nearly 6,400 patients of the Alvin C. York VA Medical Center will receive letters notifying them that they could have come in contact with contaminated endoscopic equipment if they received a colonoscopy there between April 23, 2003, and Dec. 1, 2008.
On Dec. 1 during a screening procedure, VA workers discovered an incorrectly assembled piece of equipment used in irrigation, said Chris Conklin, spokesman for the Veterans Affairs Health System, which oversees the York clinic.
Officials immediately launched a safety investigation that involved the VA's national patient safety center. They found that improper use of the equipment could have spread bodily fluids from one patient to another, Mr. Conklin said.
TO GET CHECKED OUT
The Alvin C. York VA Medical Center in Murfreesboro, Tenn., is offering free blood tests and medical care to patients who had colonoscopies there between 2003 and 2008. Patients can call 877-345-8555 Monday through Friday from 8 a.m. to 7 p.m. to schedule an appointment.
The investigation also found that a separate tube used externally during colonoscopies may have been changed improperly between procedures, a news release said.
"We are pretty sure that it is human error. Our suspicions are that it happened in-house," Mr. Conklin said.
All equipment problems have been corrected, and the letters advise the veterans to seek medical testing to ensure they were not exposed to any infectious diseases, Mr. Conklin said.
The York center is offering free blood tests and medical care to patients who had colonoscopies there between the dates in question.
VA officials apologized in a news release.
"Our top priority is to ensure our patients are safe," Juan Morales, director of VA Tennessee Valley Healthcare System, said in the release. "Although there is a very small chance patients were exposed to infection, it is our practice to notify those under our care of even the slightest risk."
The past couple of days have been agonizing for TVA retiree Gary Simpson, who served in the U.S. Army from 1970 to 1974. The Spring City, Tenn., resident had a colonoscopy in 2007 and received his letter Wednesday.
Mr. Simpson, 57, said he immediately scheduled a blood test with his family doctor. He is awaiting results of tests for HIV, hepatitis and colon infection, he said.
"I'm just overwhelmed," Mr. Simpson said. "I'm still in shock by the fear of diseases like that."
Mr. Simpson's wife of 32 years, Janice, said she hardly slept Wednesday night, thinking about what they might find in the blood test.
"It's absolute terror. It doesn't seem real," she said.
Officials could not determine when the endoscopic equipment, used in all colonoscopies, was assembled improperly, so they are casting a wide net in their notification process. Everyone who has had a colonoscopy since the equipment was introduced in April 2003 will receive a letter, Mr. Conklin said.
"We are taking an ultraconservative approach," he said.
The U.S. Department of Veterans Affairs is planning a "special" safety training session in March for staff members at all medical centers and outpatient clinics. The training follows inspections at the Murfreesboro facility and a facility in Augusta, Ga., according to a Monday VA news release.