Valve Problem Cited In Colonoscopy Issue
At Least 2 Patients At Risk For Infection, Says Hospital
POSTED: 1:20 pm CST January 8,
2009
UPDATED: 6:57 pm CST January 8,
2009
MURFREESBORO, Tenn. -- A veterans hospital in Murfreesboro is revealing more information about what may have put some patients' health in jeopardy.
Video: Wrong Valve Cited For Colonoscopy ProblemOfficials at York Veterans Administration Hospital said a wrong valve was apparently placed on a machine used during a colonoscopy on Dec. 1, putting at least two patients at risk."I first want to say that any concern with this procedure has been addressed, and we believe was limited to a single occurrence," said Tennessee Valley Healthcare System Director, Juan Morales."It was discovered there was abnormality in the functioning of the equipment used to flush water through the colonoscope," said Dr. Walter Smalley.Simply stated, the wrong valve was used during three colonoscopies that day, possibly leading to contaminated fluids being pumped back into patients."The proper valve would have only allowed one-way flow from a clean water supply into the tubing, while the one used Dec. 1 allowed two-way flow," said Smalley.Smalley, who is the chief of the gastrointestinal lab at the Nashville Veteran's Hospital, explained that the valves are the same color, size and weight. The only difference in the right and wrong valve is one less wing.A two-way valve is not used on any other piece of gastrointestinal equipment, so how the wrong valve was put on for the procedures on Dec. 1 is still unknown.The director of research for a company that cleans these machines told Channel 4 on Thursday that the valves can be easily confused."In this drawer it becomes a potpourri of reprocessing adapters, in which case it is quite possible that someone could pull out an improper adapter and connect it to the endoscope," said Dr. Lawrence Muscarella, the director of Custom Ultrasonics Equipment.The VA said an investigation is continuing into how the valve mistake happened, and whether it actually was just a one-time occurrence.The VA said the patients who were at risk will be offered testing against viruses or other illness. It is unclear if the testing will be free of charge.The affected patients should know within six months whether they are clear of complications or disease.Patients at York VA Hospital who still have concerns can call the hospital at 615-225-2560.
Video: Wrong Valve Cited For Colonoscopy ProblemOfficials at York Veterans Administration Hospital said a wrong valve was apparently placed on a machine used during a colonoscopy on Dec. 1, putting at least two patients at risk."I first want to say that any concern with this procedure has been addressed, and we believe was limited to a single occurrence," said Tennessee Valley Healthcare System Director, Juan Morales."It was discovered there was abnormality in the functioning of the equipment used to flush water through the colonoscope," said Dr. Walter Smalley.Simply stated, the wrong valve was used during three colonoscopies that day, possibly leading to contaminated fluids being pumped back into patients."The proper valve would have only allowed one-way flow from a clean water supply into the tubing, while the one used Dec. 1 allowed two-way flow," said Smalley.Smalley, who is the chief of the gastrointestinal lab at the Nashville Veteran's Hospital, explained that the valves are the same color, size and weight. The only difference in the right and wrong valve is one less wing.A two-way valve is not used on any other piece of gastrointestinal equipment, so how the wrong valve was put on for the procedures on Dec. 1 is still unknown.The director of research for a company that cleans these machines told Channel 4 on Thursday that the valves can be easily confused."In this drawer it becomes a potpourri of reprocessing adapters, in which case it is quite possible that someone could pull out an improper adapter and connect it to the endoscope," said Dr. Lawrence Muscarella, the director of Custom Ultrasonics Equipment.The VA said an investigation is continuing into how the valve mistake happened, and whether it actually was just a one-time occurrence.The VA said the patients who were at risk will be offered testing against viruses or other illness. It is unclear if the testing will be free of charge.The affected patients should know within six months whether they are clear of complications or disease.Patients at York VA Hospital who still have concerns can call the hospital at 615-225-2560.
Previous Stories:
- January 1, 2009: Pulaski Man Questions Recent Colonoscopy
- January 1, 2009: Hospital Investigates 'Possible Infection Threat'
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