Miami Herald - June 25, 2009
Lesley Clark and Fred Tasker, lclark@MiamiHerald.com

WASHINGTON -- The director of the Miami Veterans Affairs Health Care System told a Senate panel Wednesday the facility has taken steps to improve patient safety, but senators suggested the agency needs tightening at the very top.

Mary Berrocal's remarks came as the second congressional panel in little more than a week assailed veterans' officials for mistakes with improperly sterilized medical equipment that may have exposed thousands of veterans to diseases such as HIV and hepatitis.

Berrocal, whose Miami facility is one of four nationwide to report such incidents, told the panel "patient safety is the responsibility of everybody in the medical center.

"We've taken steps," she said, noting that a patient safety officer now reports directly to her and leadership weekly.

But Sen. Daniel K. Akaka, D-Hawaii, chairman of the Senate Veterans' Affairs Committee, suggested the problems require more oversight at the top.

"It is clear in the wake of these and other complaints that VA has become too decentralized," Akaka said in a prepared statement for the hearing.

"Oversight has been ceded to individual hospitals with little to no direct oversight by VA's central office."

He said after the hearing that he planned to work with the administration to make changes.

"VA's national leadership must retake control and hold personnel accountable," he said.

NEW STANDARDS

The VA announced it will spend $26 million in its facilities to purchase new reusable medical devices and help staff adhere to new standards.

Senators questioned why -- after repeated alerts from the VA and media reports about the problem -- fewer than half of VA medical facilities reviewed during a surprise inspection could provide evidence of proper procedures and training.

"This is a very, very serious issue," said Sen. Richard Burr, R-North Carolina. 'I'm here, after 11 alerts, to say: 'Enough is enough.' "

Gerald Cross, acting undersecretary for health at the Department of Veterans Affairs, said he was "distraught" by the findings of the surprise inspections.

"I was very disappointed," Cross said. "We did something wrong, and I expect it to be corrected."

UNANNOUNCED VISITS

He said that by July 14, the Washington VA staff will have made unannounced visits to every VA health facility in the nation to ensure that staff training cleaning of colonoscopy and endoscopy equipment is documented.

He said the probability that any veterans contracted an infection "as a result of our inadequate" cleaning was "very low" but that the department would care for the veterans, "regardless of the source of infection."

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