MD: Wrong Valve Carries Hepatitis, HIV Risks

Reported By Deanna Lambert

All V.A. Medical Centers Surveyed After Colonoscopy Health Instrument Issue

NASHVILLE, Tenn. -- Medical staff from the Tennessee Valley Healthcare System offered apologies and took questions from the media Tuesday morning, but they didn't have many answers.

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"We still don't understand how this incorrect valve with the right length tube came into existence," said Dr. Walter Smalley. "We don't know if it came to us from the manufacturer or if someone, in an effort to clean things here, took things apart (and) put things back together the wrong way."

Olympus manufactures the equipment, and, according to a representative, the valves and tubes come attached to each other.

After the colonoscopy procedure, some parts are supposed to be thrown away and others reused. The parts that are reused are sent to the hospital's sterilization, processing and distribution unit.

The root problem is that two valves that look very similar. One is used for patients' procedures; the other is used for cleaning. To prevent future problems, medical personnel have attached a blue clip, clearly indicating that the instrument is not for patient use.

According to the quality assurance director with the Department of Veterans Affairs, the manufacturer has never had a report of the wrong valve connected to the tube.

All 153 V.A. Medical Centers were then surveyed.

"It was only Murfreesboro that had this problem," said William Duncan, M.D.

On the 10 to 15 setups in Murfreesboro, only one setup had the wrong two-way valve.

But one wrong setup has many major risks:

"Those main risks are Hepatitis B, Hepatitis C and HIV," said Smalley.

V.A. officials said their investigation is complete and that no one has transmitted a disease or experienced major sickness as a result of all this already.

Officials also said no staff have been fired or forced to resign over the matter.

If you've had a colonoscopy at the York V.A. Center between April 2003 and last December, there's a dedicated phone line available to answer your questions. You can call 1-877-345-8555 Monday to Friday, 8 a.m. to 7 p.m. (CST).