The problem of sewer water leaking on surgical patients at the Carl T. Hayden VA Medical Center in Phoenix began as early as April of 2009, a newly obtained report shows.
Until we received the report today, we'd been under the impression that two incidents of water leaking into the open surgical wounds of patients happened within weeks of each other last summer.
The anonymous letter-writer who first tipped us off in October mentioned that he or she had heard of two instances of water dripping on patients during surgery "in the last six months." Officials at the VA agreed there were two such occurrences, and seemed to concur about the timing. At least, the VA made it seem as though it was on the ball in a written statement to New Times:
This happened on two separate occasions.
(Hospital staff) responded immediately with corrective actions and sealed the penetration points between the 4th and 3rd floor directly above OR 5 alleviating any further such outcomes.
Gee, "responded immediately" makes it sound like there's just no way the first incident could have occurred a full 16 months before the second incident, right?
Yet that's just what happened.
On April 27, 2009, a 64-year-old "non-service-connected" veteran was having vascular surgery on his leg when a clear liquid dripped from the ceiling "onto the operative field."
"Surgeon immediately threw a towel over the wound site," says the April 28, 2009, VA issue brief.
The operating table was moved to a new room and the veteran was given a slew of anti-biotics.
"It was later determined that the leak was from a plugged rain on an inpatient ward on the floor above the operating room, which caused sewer water to back up and overflow," the report says. "The leak also affected the anesthesia supply room. Contaminated supplies were removed, ceiling repaired and room cleaned."
The VA recommended that the veteran be monitored for "possible deep wound infection" for at least a year.
The incident prompted a meeting between the hospital's chief of staff, the doctor from the surgery, a quality manager, and a regional lawyer. The plugged drained was cleaned.
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SHOW ME HOW
Then, more than a year later, a veteran was dripped on during surgery. And once again, the leak affected the anesthesia supply room.
The August incident, along with other allegations, resulted in the hospital's practices and surgical facilities being reviewed by an inspection team. The hospital apparently passed the inspection, but officials say they can't reveal the team's findings due to privacy laws.
We've never run a hospital, but the 16-month delay in fixing the pipework (if it really is fixed) seems excessive. Letting a patient get dripped on for a second time, after having 16 months to fix a problem, also seems lame. Plus, if our anonymous letter-writer is correct, (a good bet, at this point), then the VA is holding back reports on one or two other water leaks.
Even if it was just these two leaks, the long delay and second occurrence of the problem before anyone addressed it effectively smacks of a breakdown not just of plumbing, but of management.