VA clinic patients may have been exposed to hepatitis, HIV

Jun 29, 2010

Failure to properly clean dental instruments may have put more than 1,800 patients at a Veterans Affairs (VA) clinic at risk for hepatitis and HIV.

Patients who went to the John Cochran St. Louis VA Medical Center dental clinic in Missouri between February 2009 and March 2010 may have been exposed, according to a report by KSDK TV. The VA began notifying 1,812 potentially at-risk patients via certified letters on June 28.

Gina Michael, M.D., the association chief of staff at the hospital, told KSDK that some dental technicians used "a sink and strong soap" to clean the tools rather than sending them to the hospital sanitizing and sterilizing department. The technicians "were trying to protect the delicate instruments," she said. Although the instruments were also sterilized, the process may not have been enough to kill certain viruses, the hospital said.

The hand cleaning was discovered by a team from VA headquarters during a routine inspection, KSDK reported.

The clinic released the following statement:

The St. Louis VA Medical Center is notifying 1,812 veterans of the availability of free screenings for infections for those individuals who had procedures performed in the dental clinic, John Cochran Division, from February 1, 2009, through March 11, 2010.

These patients may have been inadvertently exposed to viral infection. As a result of quality reviews, it was determined that some of the steps involved in the preparation of the dental instruments for sterilization were not in compliance with our standards.

Though we believe the health risk is extremely low, it was not possible to rule out the possibility that one or more patients were exposed to an infection. In accordance with leadership's commitment to ethical decision-making, we have decided to notify patients of the situation. This conservative approach is in the best interest of our veterans and is consistent with VA's policy to disclose all significant and potentially significant adverse events to patients.

The hospital has set up a special clinic for those patients who may be at risk and also a Dental Review Clinic Call Center to enable those veterans who are notified to make expedited appointments and receive additional educational information.

On June 29, Rep. Russ Carnahan (D-MO) sent letters to President Barack Obama and Secretary of Veterans Affairs Eric Shinseki insisting they immediately investigate this breach of standard operating procedures and report back what will be done to remedy the issue and ensure that it doesn't happen again. Carnahan has also contacted House Committee on Veterans' Affairs Chairman Bob Filner to schedule a hearing as soon as possible to look into the matter.

"This is absolutely unacceptable," Carnahan said in a statement on his website. "No veteran who has served and risked their life for this great nation should have to worry about their personal safety when receiving much needed healthcare services from a Veterans Administration hospital."