New Report Reveals Widespread Problems with Endoscopy Cleaning Procedures at VA

Even after problems were found with how endoscopes were cleaned at three Veterans Administration medical centers earlier this year, surprise inspections found that over half additional VA medical facilities visited could not demonstrate compliance with proper procedures for safely cleaning endoscopes after each use.

A report revealing the extent of problems from the VA Office of the Inspector General was discussed during a hearing of the House Veterans Affairs Subcommittee on Oversight and Investigation on July 16, 2009.

Congress member Steven Buyer, Ranking Member of the House Committee on Veterans Affairs, who requested the meeting to review the report said:

I asked for the InspectorGeneral to become involved after the Miami incident, because I suspected the problem was systemic. Now that we know it is, I am deeply concerned that this problem is expansive and it goes well beyond VA. What is happening at HHS and the Department of Defense? What is happening in our greater health system?

On May 13, 2009, VA inspectors made visits to 42 randomly selected VA medical facilities that performed colonoscopies or ear, nose, and throat (ENT) endoscopies. Reporting on the 38 visited facilities that did colonoscopies, the inspectors found:

  • 82 percent had locally-developed standard operating procedures based on manufacturers cleaning and maintenance manuals easily accessible for employees to use.
  • 53 percent had records of employee training and skills with proper set-up and cleaning procedures
  • 47 percent had both SOPs and competence documentation

The Inspector General’s Report said,

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.

Manufacturers provide instructions for maintaining and cleaning equipment, and often they train staff in how to clean endoscopes when they are first purchased. However, as staff turn over, facilities need to have training and supervision in place to be sure that new staff understand the procedures and all staff follow them.

March 8-14, 2009 was a system-wide Endoscopy Set-Up Week for all VA medical facilities that do colonoscopies.  During that week, facilities were required  to make sure that the following were in place:

  • locally developed standard operating procedures for setting up and cleaning every device used based on manufacturers recommendations
  • evaluations of model-specific competence for employees who set up or clean endoscopy equipment
  • assured accountability for set-up and cleaning procedures in all areas and at all levels of the organization

The random inspections were conducted on May 13, 2009, two months after Set-Up Week.

Since endoscopes are reused and not thrown away and since they cannot be sterilized like some other surgical equipment, they must be carefully cleaned and sanitized after every patient use.

The Inspector General’s Report points out five key steps in decontaminating endoscopes:

  • Pre-cleaning and scrubbing to remove all debris and body fluids from inside and outside surfaces. This is typically done by a nurse or technician right after the procedure.
  • Disinfection by soaking the instruments in a disinfectant solution that is able to reach all areas of the equipment.
  • Rinsing all surfaces with sterile, filtered, or high-quality drinking water to remove disinfectant.
  • Flushing channels with alcohol to dry them, followed by forced-air drying.
  • Storage in well-ventilated dry spaces, hung according to manufacturer’s recommendations.

From October 1, 2008 through May 23, 2009, nearly 200,000 gastrointestinal endoscopies were  performed in VA facilities, 142,500 of them colonoscopies.


  1. Kate Murphy says

    Problems were found at the Alvin York Campus of the Tennessee Valley VA System in Murfreesboro, TN. Patients who had a colonoscopy there between April, 2003 and and December 2008 were notified of a risk of infection with a telephone numbers to call for more information and to schedule blood testing.

    The other center that identified problems with cleaning a water tube in the colonoscopy equipment was in Miami FL. They also notified all patients who might have been affected by letter and asked them to schedule a blood test.

    So, if you are a veteran at risk right now, you should have received a letter from the VA asking you to schedule an appointment for blood testing.

    Patients who had colonoscopies in VA Medical Centers other than Murfreesboro or Miami are not being considered at risk for infection right now. BUT if you have questions or think blood testing is important to you, contact your own VA Medical Center and ask them.

    There is more information about this issue on the C3 Research News:

    Improperly Cleaned Endoscopes Raise Infection Risk in VA Facilities.

    If you have any doubts or concerns, call your own VA facility or the center where you had your colonoscopy.

  2. Kim Ryan says

    Hello Conrad,

    Thank you for taking the time to inquire about the specific VA’s that reported problems. The three were Murfreesboro, TN, Miami, and in the ENT clinic in Atlanta.

    Please let us know if you should have any further questions.


    Kim Ryan
    Director of Patient Information Services

  3. Conrad Creitz says

    Could you publish a list of all the VA’s that had problems with the cleaning of endoscopes?
    It would help all Veterans to know if they had a problem.
    I am a colon cancer survior which I blame on Agent Orange.

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