Nearly seven months before a patient at Charlie Norwood VA Medical Center noticed a problem with sterilizing equipment, setting off a national investigation that found thousands of patients potentially exposed to infection, an employee pointed out problems with sterilization of that equipment.
Augusta VA officials insist the employee was relying on misinformation that would not have caught or corrected the problem.
After the patient's discovery in November 2008, the VA notified more than 10,000 veterans that they might have been exposed to improperly cleaned equipment, and it offered testing. More than 50 cases of infection, from hepatitis C to HIV, have since been found, though VA officials say it's unlikely they came from the equipment.
Seven months before others noticed, in April 2008, an Augusta VA employee sent out an e-mail raising alarm about the sterilization of flexible endoscopes, according to information obtained by The Augusta Chronicle.