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MEMPHIS, TN – The federal government is planning an investigation of a Memphis hospital run by the Veteran’s Affairs (VA) after a whistleblower came out saying the facility used contaminated dialysis machines. The identify of the whistleblower is unknown, but the level of knowledge and contact with staff indicates he is someone that conducts business or is employed at the hospital or is a patient.
This new information about contaminated dialysis machines adds to the problems the hospital has been facing. In 2012 the VA Inspector General reported that the Memphis VA hospital suffers from “chronic overcrowding,” claiming many emergency room patients wait six hours or more to be seen. In 2013 the Office of Inspector General investigated three deaths at the hospital. One resulted in a family questioning the care their loved one received while at the hospital. The recent whistleblower claims that eight of the VA medical center’s thirteen dialysis machines are highly contaminated.
Apparently the potential contamination issue was discovered after the person responsible for cleaning the dialysis machines learned she spent years doing it wrong. “She told him she was putting in 20 cc’s of the cleaning solution, and the technician informed her she should have been using 20 ounces,” the whistleblower said.
In a Fresenius hemodialysis machine operator’s manual there are thirteen pages dedicated to disinfection, cleaning and maintenance. Most modern dialysis machines come with systems that automate many of the cleaning and disinfection procedures. It’s simply a matter of the technician completing all the required steps with the proper solutions and amounts. Every dialysis machine is different. Cleaning the dialysis machine often requires a rinsing process, acid cleaning, chemical rinse, chemical dwell, as well as an acid & heat disinfection. Technicians usually clean the exterior of the dialysis machine as well as check for leaks and spills. If this cleaning process is not done properly, blood from the previous patient may remain in the machine or harmful chemicals may be introduced into a patient’s blood stream. That’s what makes the issue at the Memphis VA hospital so concerning. “All I could think about was how I would feel if someone came and told me, ‘I came to the VA to get dialysis treatment, and I got HIV or hepatitis,’” said the whistleblower.
Local CBS news station WREG requested test results or cleaning and maintenance logs for dialysis machines, indicating that in fact the man did work at the hospital. The whistleblower failed to respond. Reiterating his belief that patients have been exposed to contaminated dialysis machines, he simply said, “Anybody that came through dialysis, I would say probably in the last 10 years should have some concerns.”