news

Congresswoman Debbie Dingell (MI-12) today sent a letter to VA Ann Arbor Healthcare System Director Robert P. McDivitt following reports that recent surgeries for veterans were canceled or moved to another facility because particulate matter was observed on sterile surgical equipment. The VA Ann Arbor Healthcare System was investigated in 2014 for a similar issue, and the U.S. Office of Special Counsel and the VA Inspector General later issued a report verifying that changes were made at the VA to solve the problem.

“While recognizing you are cancelling and moving surgeries to ensure no veterans are being put at risk, this situation is still concerning and raises questions about the source of this particulate matter and what actions are being taken to correct the problem,” wrote Dingell. “We want to work with you to ensure you have the necessary resources to identify and rectify the problem so everyone can have the highest confidence in the condition of the facilities which our veterans rely on.”  

Dingell requested information about the status of construction of the new Sterile Supply Service area, which was a focus of the 2014 investigation, as well as steps and procedures put in place to ensure that patient safety is not compromised.  

“Our veterans have made numerous sacrifices for our nation, and we have an obligation to make sure they are properly cared for,” she continued. 

The full text of the letter is available here and below. 

November 23, 2015

Mr. Robert P. McDivitt
Director 
VA Ann Arbor Healthcare System
2215 Fuller Road
Ann Arbor, MI 48105

Dear Director McDivitt:

Thank you for speaking to me earlier today in response to a phone call I received from a concerned party about the recent cancellation of surgeries for veterans at the VA Ann Arbor Healthcare System.  It is my understanding that nurses in the operating room first began noticing particulate matter on sterile surgical equipment and, as a result of their vigilance and the administration’s actions to ensure the safety of all patients, surgeries have been cancelled or moved to the University of Michigan.  Staff at the hospital deserves credit for their awareness and for recognizing and diligently reporting these incidents.  While recognizing you are cancelling and moving surgeries to ensure no veterans are being put at risk, this situation is still concerning and raises questions about the source of this particulate matter and what actions are being taken to correct the problem. 
 
This situation is even more concerning in light of the fact that the U.S. Office of Special Counsel and the Veterans Affairs Office of the Medical Inspector investigated allegations of improper sterilization of surgical equipment at the Veterans Affairs Medical Center in Ann Arbor last year.  We want to work with you to ensure you have the necessary resources to identify and rectify the problem so everyone can have the highest confidence in the condition of the facilities which our veterans rely on.  Therefore, I respectfully request answers to the following questions. 
 
1.    To the best of your knowledge, what is the source of the particulate matter that is being seen on surgical equipment?  What resources are you committing to this investigation?  What outside expertise have you brought in to help identify the problem?

2.    How many veterans have had surgeries cancelled or moved to another facility because of this issue?  What actions are being taken to help facilitate those impacted by these changes? 

3.    What steps and procedures have you put in place to ensure that patient safety is not compromised at the Ann Arbor VA Medical Center?  Please provide a detailed response. 

4.    The 2014 investigation by the Office of Special Counsel focused in part on the construction of the new Sterile Supply Service area.  Has this construction been completed?  Could this be the source of the particulate matter being seen on surgical equipment?  How will this new area improve operations at the Ann Arbor VA Medical Center? 

5.    What is the penalty for a staff member who accidentally or purposefully contaminates sterile equipment?  What policies and training procedures do you have in place for operating room staff to prevent these incidents from happening before they occur?

6.    Do you have the resources you need to complete this investigation and to take remedial action to correct this problem?  If not, what resources do you need to do a complete and thorough investigation?

Thank you for your attention to these critical issues.  Our veterans have made numerous sacrifices for our nation, and we have an obligation to make sure they are properly cared for.  Your answers will help ensure that all appropriate actions are being taken to ensure this issue is properly addressed and that you have the resources you need to do the job.  I look forward to receiving your response and working with you to ensure our veterans are receiving the highest level of care. 
 
Sincerely, 

Debbie Dingell
Member of Congress