Recently, more than 570 veterans in upstate New York received some dire news that could be classified as tragic irony: After they have survived wars and occupations overseas, the very health system that was meant to protect them at home — the United States Department of Veterans Affairs (VA) — could ultimately end up being the very thing that kills them.
Seven hundred sixteen vets (146 now deceased) who were served by the Buffalo VA Medical Center could have been exposed to HIV or hepatitis from reused insulin pens. Hospital staff did not follow protocol (some people believe that necessary protocol didn’t even exist at the VA) and failed to, one, dispose of the one-time use pens, and, two, label the pens by individual patient if the incorrect assumption did exist that they were intended to be used more than once. A routine inspection brought this despicable behavior to light, discovering the unlabeled, previously used pens in supply carts ready to be used again.
This is not the first HIV scare to plague the VA and its patients. In early 2009, the VA launched an internal investigation to figure out how it was possible that 10,000 patients from VA hospitals in three states (Florida, Georgia, and Tennessee) were put at risk of contracting HIV and hepatitis after unsterilized colonoscopy equipment was repeatedly used — the tubes used in the procedure were only rinsed, never disinfected. After checking every one of the individuals exposed to the dirty tubes, it was found that 16 of them were infected — 10 with hepatitis and six with “unspecified viral infections”.
What makes these incidents so disconcerting is that the VA never learned from its mistakes. As a matter of fact, mistakes don’t even represent a catalyst for change within the organization. That was made evident during the 2009 HIV scare when, three months after the initial announcement of the colonoscopy nightmare, the VA discovered that half of their medical centers still had not developed standardized cleaning procedures, nor could they show that they properly trained their staff for using the equipment. If the thought of infecting a patient — or the liability that comes with it — wasn’t enough to facilitate change, then what would be?
That’s the difference between the public sector and the private sector. In the world of private medicine, one HIV scare is more than enough. It would have set off an immediate domino effect by which capable and accountable people would have initiated the necessary changes to policy and procedure, not only with the failed practice in question, but also with a myriad of practices and equipment that could potentially create similar risk. Whereas the private sector reacts immediately and with purpose, the public sector moves at a snail’s pace, if even at all.
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Bob Confer (photo)