Oops! My bad

A U.S. House panel last week heard testimony that the Department of Veterans Affairs and the Food and Drug Administration are having a failure to communicate. That actually sounds nicer than saying a lack of communication put veterans undergoing surgery at risk for diseases such as HIV and hepatitis or even worse. According to the press release from the House Veterans Affairs Committee:

“The hearing addressed several issues that together had suggested problems with VA health care quality assurance. In February, surgeons at the James A. Haley VA Medical Center (VAMC) in Tampa, Fla., implanted an unsterilized cranial plate in a patient and nearly duplicated the mistake a week later. In April, VA discovered that it was improperly cleaning and sterilizing prostate biopsy devices, called transrectal ultrasound transducers, at the Togus VAMC in Maine. According to Dr. James Bagian, VA’s chief patient safety officer, unclear labeling and confusing instruction manuals contributed to the errors with the transducers and cranial implants.”

Believe me, or not, the last thing one would want is some unsterilized transrectal something in their prostate much less an unsterilized anything in one’s cranium.

The “Ya think?” quote from that session is courtesy of U.S. Rep. Silvestre Reyes, D-Texas:

“Clear and unambiguous labeling of the sterility of medical implants should be mandatory,”” said Reyes. ““This would seem to be a necessary and fundamental procedure. Yet when senior physicians reach different conclusions about whether a medical implant is or is not sterile, or about the process to sterilize that implant, we have a problem. Hospital staff should not have to read the tiny print on the bottom of page three of instructions after a patient is prepared for surgery.”

And when I say: “Ya think?” I mean it in a good way. Huh?

Veterans who had the prostate procedure were supposedly sent letters warning them of “a small risk of exposing patients to Hepatitis B, Hepatitis C and the Human Immunodeficiency Virus (HIV).” Out of the goodness of the hearts of the VA, patients who had the procedure can be tested for these diseases at no cost. Did you hear me? I said: “No cost.” Talk about a deal.

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