Medical Mistakes at VA Hospital Slammed by Congress

Unhappy with the slow pace of improvements at a Veterans Administration (VA) hospital in Miami, where thousands of veterans were exposed to unsterilized colonoscopy equipment in 2009, lawmakers are calling for the ouster of the center’s director. 

At a congressional hearing of the House Veterans’ Affairs committee last week, congressmen on both sides of the aisle said Mary Berrocal, the hospital’s director, has been too slow in making improvements at the facility. Some also suggested that Nevin Weaver, the regional VA director, should be replaced as well.

The most recent problem at the hospital occurred in August, when Catawaba Howard, a 32-year-old Air Force veteran, was supposed to be held in the hospital due to psychiatric problems, but was released when staff became confused about whether she was voluntarily or involuntarily committed. Howard was subsequently shot and killed by a Miami-Dade police officer responding to a domestic disturbance after she reportedly shot at two officers.

Berrocal was officially admonished by a VA board for failing to notify local veterans that they had potentially been exposed to infected blood in 2009, but was allowed to keep her job.

The VA Clinic problems were linked to the use of contaminated endoscopic equipment used for colonoscopy tests and ear, nose and throat exams. Human error and improper training has been blamed for equipment not being sterilized between patients and other improper procedures that potentially exposed veterans treated to bodily fluids of other patients.

The colonoscopy contamination issues were first discovered in December 2008, at the Alvin C. York Medical Center in Murfreesboro, Tennessee. A subsequent review of procedures at all VA Clinics led to the identification of additional issues in Miami and at the Charlie Norwood VA Medical Center in Augusta, Georgia.

About 2,500 patients treated at the Miami VA hospital told in 2009 that they should obtain blood tests, and at least five cases of HIV have been found among those exposed at the facility. Another eight Miami VA patients have been diagnosed with Hepatitis C and one has been diagnosed with Hepatitis B.

Not much has improved for Miami veterans who depend on the facility for medical care, lawmakers said. It took the facility a year before it notified nearly 80 vets that they might have been exposed, and another dozen veteran patients were not notified until earlier this year.