Missed pre-cleaning step leaves 267 VA patients at risk for infection from scope

After a deviation from standard cleaning protocols for endoscopy scopes, the U.S. Air Force Academy's Medical Clinic in Colorado and the VA Eastern Colorado Health Care System are together notifying 267 GI clinic patients of a potential infection risk.

The VA Eastern Colorado Health Care System and the USAFA's Medical Clinic have partnered since 2011 to provide care to patients at the clinic on Academy grounds. Of the 267 patients at risk, 206 were under USAFA's Medical Clinic care, while the remaining 62 were VA patients. All potentially affected patients, who visited the clinic between June and September, are being offered testing.

According to the USAFA Medical Clinic, all steps of high-level disinfection were completed properly on the endoscopes, but a pre-cleaning process step "may have been omitted." All 19 scopes were investigated and had no infectious material present, but there is still a low risk of infection.

The clinic has stopped performing any GI endoscopy procedures while the issue is being investigated. The VA and the clinic are also work with the endoscope manufacturer so workers can be retained and recertified for scope cleaning.

"Maintaining safety and quality is our top priority. We take any potential risk to patient safety very seriously and are committed to informing those under our care of any increased risk," said Col. Walter Matthews, MD, command surgeon of the Air Force Academy.

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