TAMPA, Fla. (AP) – Staff members at the nation’s busiest VA hospital failed to ensure that cranial implants prepared for two recent operations had been sterilized, an investigation found.

A subcommittee of the House Veterans Affairs Committee said Monday that it will investigate the problems at the James A. Haley VA Medical Center in Tampa.

An investigation by the VA inspector general found that in one of the two cases in February surgeons inserted an unsterile plate in the skull of a patient who had been injured in a traffic accident, but there was no evidence of complications.

A week later, surgeons averted a similar mistake only because the implant did not fit the patient, who had been injured by a roadside bomb in Iraq. The surgical staff assumed incorrectly that the implant had been sterilized by the manufacturer, the statement said.

The report noted that the hospital lacked a uniform process of delivering equipment to the operating room and determining sterilization needs of prosthetic products.

VA spokesman Phil Budahn in Washington declined to comment.

Haley had 148,000 patients who logged in 1.5 million visits last year. Its polytrauma unit is one of only four in the VA system that specializes in treatment of a new generation of combat injuries caused by improvised explosive devices such as those used Iraq.

The subcommittee said it had learned of a similar case of improper sterilization of a medical device at Togus VA Medical Center in Augusta, Maine.

The Maine case involved a device used during prostate ultrasounds and came to light earlier this year, said Jack Sims, director of the Togus VA. The discovery led to a review that’s still under way.

as well as a change in sterilization procedures for that component, he said.


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