KANSAS CITY, Mo. - An NBC Action News investigation has uncovered spotted and rusty surgical instruments at the Kansas City Veteran’s Administration Hospital.
Startled OR doctors cancelled operations and eventually shut down operating rooms before any of the instruments were used according to hospital officials.
An insider at the VA Hospital tipped off the NBC Action News Investigators to the problem Monday.
By Tuesday, NBC Action News had confirmed dozens of cancelled operations due to what was initially a mysterious residue on surgical instruments
In addition to unexplained cloudy residues, operating room workers at the VA found rust on some surgical instruments, creating a week of rescheduled procedures and scattered cancellations as officials scrambled to figure out what was wrong.
“For a period of a day or two we cancelled all surgeries,” said Dr. James Sanders, the chief of staff at the VA.
Tests showed, despite the residues, everything was sterile.
But it took a week before a chemist determined the problem was the acidity level of the hospital’s sterilization fluid.
The stains disappeared by adding the equivalent of sterile lemon juice to the hospital’s deionized sterilization water.
Kansas City's VA has improved its ranking from 124th three years ago to 67th at last report out of 138 medical centers nationwide, according to a document provided by the hospital.
A VFW spokesman criticized the Kansas City's hospital's public disclosure of the event, saying the group wasn't notified.
“It would have been nice if we were notified,” Joe Davis, national spokesman for the Veterans of Foreign War, said. “It wouldn't be prudent for the VFW to comment, other than to say patient safety must always come first, which appears to be what VA did when they closed the OR and then made repairs to its water treatment and sterilizing system.”
Ongoing federal inquiries at VA hospitals in Florida, Tennessee, and Georgia recently found unsanitary equipment that potentially exposed thousands of veterans to contagious disease, but officials say that's not what happened in Kansas City.
“Absolutely not,” Sander said emphasizing not one of the spotted instruments was used on any patient. “Any spotting that was found was found as part of the normal process to inspect the instruments before they go to the case.”
Sanders compared the problem to the spots you'd find on a clean wine glass fresh out of the dishwasher.
Although the surgical instruments didn’t pass visual inspections, Sanders said they were clean and sanitary.
Sanders said since resolving the problem by changing the pH balance in the sterilization fluid, the VA’s operating rooms are now back at full schedule and most of the backed up procedures have now been rescheduled or completed.
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