VA secretary: St. Louis mistakes 'unacceptable'

The Veterans Administration said Thursday that the chief of dental services at a St. Louis VA Medical Center has been placed on administrative leave after the hospital urged nearly 2,000 veterans to return for blood tests because inadequately sterilized equipment may have exposed them to viral infections during dental procedures.

An independent board will also investigate how employees failed to properly sterilize the dental equipment that potentially exposed veterans to infections including hepatitis and HIV, the administration said.

"The mistakes made at the St. Louis VA Medical Center are unacceptable, and steps have been and continue to be taken to correct this situation and assure the safety of our veterans," VA Secretary Eric Shinseki said.

The VA sent letters out Monday to 1,812 veterans who had dental procedures at the St. Louis center from Feb. 1, 2009, through March 11 of this year, saying reviews determined that some sterilization steps in preparing dental instruments were not in compliance with standards.

Officials say the infection risk is extremely low, and no illnesses have been uncovered so far out of some 100 veterans who have come in for blood work that will screen for hepatitis B, hepatitis C and HIV. The VA said 184 people had signed up to be tested as of Thursday.

VA Under Secretary for Health Dr. Robert Petzel said Thursday the problem arose because workers prewashing dental equipment failed to use a detergent before the equipment was sterilized. He said that failure allowed for a "phenomenally remote" chance that sterilization might not have been effective.

Petzel said he found there was a need for an independent review by the national Administrative Investigation Board "to determine the reasons for failure to follow correct procedures." He said expects the investigation to begin next week and take 60 days at most.

Rep. Russ Carnahan, D-Mo., said the House Veterans' Affairs Committee also said they will investigate what happened at the center and planned to hold a hearing in St. Louis. The announced investigations follow demands for action by several lawmakers from Missouri and Illinois - the St. Louis region's five VA facilities serve veterans in both states.

No date has been set for the Veterans' Affairs Committee hearing in St. Louis. Two Missouri congressmen, Republican Blaine Luetkemeyer and Democrat William Lacy Clay, also asked the House Oversight and Government Reform Committee to investigate. Both serve on that committee.

Lawmakers also want to know why it took so long for the VA to inform the veterans about the mistakes. The problem was uncovered in March and letters went out Monday.

Marcena Gunter, a spokeswoman for the St. Louis center, said the delay was because officials were evaluating the risk posed to veterans.

The name of the suspended chief of dental services was not released.

The VA said patients who have had dental procedures since March 11 are not at risk because procedures were corrected.

Shinseki said that over the past 18 months, VA has implemented more stringent safety oversight at its medical facilities, and that oversight led to the identification of problems at the St. Louis facility.

VA centers around the country have had problems in recent years. In 2007, Walter Reed Army Medical Center in Washington came under scrutiny over concerns about conditions at the hospital and treatment of veterans. At the time, St. Louis VA officials said they were working to fix similar problems.

That same year, a surgeon at the VA hospital in Marion, Ill., resigned after a patient bled to death following gall bladder surgery. All inpatient surgeries were suspended. The VA found at least nine deaths between October 2006 and March 2007 resulted from substandard care at the Marion hospital, and another 10 patients died after receiving questionable care that complicated their health.