The U.S. Air Force Academy’s Medical Clinic and the VA Eastern Colorado Health Care System are in the process of notifying 267 gastrointestinal endoscopy patients about potential health risks associated with procedures at the Academy’s GI clinic between June and September 2016. An investigation was launched Sept. 9, once the clinic became aware of the procedural lapse, according to academy and Veteran Affairs officials. The “precautionary notification” was issued to service members, retirees, veterans and family members.
“We became aware that [the technician] had been skipping a step in the pre-cleaning process before the scopes went in for high-level disinfection,” said Col. Robert Rottschafer, USAFA deputy surgeon general. “As soon as we became aware of this, we suspended operations in the GI clinic and we began an investigation, consulting with our VA partners and bringing them in as soon as we possibly could, and made sure we understood exactly what we were dealing with.”
Of the 267 affected patients, the clinic and the VA have contacted just more than 100 patients thus far. The academy and VA are tight-lipped about the investigation, refusing to announce who is involved and whether criminal charges are possible. Officials also declined to release the identity of the technician or specify whether the tech is active duty or civilian.
“It was determined there was an extremely low risk of infection,” Rottschafer said of findings by experts, to include an infectious disease consultant to the Air Force surgeon general, the scope manufacturer and the VA’s infectious disease consultant.
“The verbiage was low [risk], but not zero. When we heard that we took steps, for transparency reasons, to make sure we are maintaining the trust and fidelity of our patient population — that we needed to contact every one of them and let them know there is an increased risk,” Rottschafer said.
Those patients are being offered lab work by their provider to test for infection, he said.
According to Lt. Col Thomas Stamp, commander of the 10th Surgical Operations Squadron, the technician determined the missed step was redundant and therefore didn’t complete it.
“Per the manufacturer’s instructions, there should be no steps skipped,” he said.
The unnamed technician had been with the GI clinic for two years and had no previous incidents, according to Stamp, who added the technician admitted to skipping the cleaning procedure since June. The technician is still employed by the clinic, but isn’t working with patients, Rottschafer said.
“We have contractors, active duty and [general schedule] employees that work in that clinic,” he said. “They work close together, side-by-side, and in the interest of the investigation, I would rather not go into identifying anybody.”
The Centers for Disease Control worked with the academy and the VA to determine infection risk, according to Ellen Mangione, chief of staff of the Eastern Colorado Veterans Health Care System. Those risks include HIV, Hepatitis B and Hepatitis C.
“I do want to emphasize, in this particular situation, we feel the risk is exceedingly, exceedingly low,” Mangione said.
“While the risk to the potentially impacted patients is very low, it cannot be discounted entirely,” said Col. Walter Matthews, Air Force Academy command surgeon in a news release. “Maintaining patient 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.”
Every patient who had a GI endoscopy at the clinic during the period indicated will be contacted by either an Air Force or VA provider and informed of potential risks. Of the 201 patients potentially impacted, 206 were under the care of USAFA’s Medical Clinic, the remaining 61 patients are affiliated with the VA.
“The clinic has placed all GI endoscopy procedures on hold pending complete resolution of this issue,” the news release stated. “In addition, the VA and academy medical clinic are coordinating with the endoscope manufacturer to provide retraining and recertification on the cleaning of scopes. All other procedures performed at this clinic are unaffected.”
When the clinic will resume its GI endoscopy procedures has not been determined.
The VA Eastern Colorado Health Care System and the academy medical clinic have partnered since 2011 to provide outpatient surgical services at the clinic on the academy to veteran patients in Colorado Springs.
Patients with questions or concerns are asked to contact the GI clinic between 8 a.m.-4:30 p.m. at 719-333-5140/5138.