Alleged Concerns in Sterile Processing Services at the New Mexico VA Health Care System, Albuquerque, New Mexico

The OIG conducted a healthcare inspection in response to allegations regarding Sterile Processing Services (SPS) at the New Mexico VA Health Care System. The OIG team did not substantiate tampering with equipment was occurring or that sterile sets were incorrectly stored or damaged. Thirty-eight of 356 sterile sets inspected were missing instruments; those sets were not consistently labeled as to which instruments were missing. Not all patient safety events were reported as required. Additionally, some surgical procedures were delayed or canceled due to unavailable sterile instruments and equipment. The OIG team determined that, while no patient experienced an adverse clinical outcome related to delays or cancellations, three patients were exposed to increased risks for adverse clinical outcomes. The contract for SPS technicians responsible for reusable medical equipment (RME) reprocessing lapsed in spring 2017. An increase in the number of surgical delays and cancellations occurred for the two months after the contract ended, but the OIG could not establish the surgical delays were related to SPS staffing. Deficiencies in the documentation of SPS staff training and competency records as well as in the maintenance of a comprehensive list of RME and standard operating procedures for some items were identified. The OIG determined the VISN did not provide effective oversight and the facility did not effectively implement proposed action plans, as evidenced by recurring findings reported in multiple inspections. The OIG made 12 recommendations related to missing instruments, verification of items in sterile sets, accurate patient safety event reporting, SPS training, maintenance of an accurate RME list, standard operating procedures, competencies, a review of the SPS contract, implementation of actions from previous reviews and this review, evaluation of the SPS risk assessment, and independent verification by VISN staff, if necessary, to implementation of action plans related to SPS recommendations.