WASHINGTON, (NBC) - Officials with the Veteran's Administration, the V.A., were hauled up to Capitol Hill Tuesday to answer for medical mistakes that left thousands of veterans at risk for H.I.V. and Hepatitis.
It happened at four V.A. hospitals, but an internal report just released shows problems throughout the system.
The V.A. is vowing to 'clean up' it's act, literally, after warning thousands of vets they may have been infected over the last five years because workers failed to properly clean medical equipment.
Michael Priest, a U.S. Navy veteran, went to the V.A. for a colonoscopy. But because someone didn't clean the equipment properly, he may have been infected.
He tested positive for Hepatitis B and H.I.V. "It was just, it just was devastating. It was really terror," said Priest . Later tests came back negative but the anxiety lingers, for Priest and more than 10,000 other veterans who've been warned they may be at risk.
"Going in for a routine colonoscopy and being contacted later that you may have Hepatitis or H.I.V. isn't just an adverse event - that's catastrophic," said Representative Tim Waltz (D) Florida.
The V.A.'s identified four facilities in Tennessee, Georgia, and Florida where tubing either wasn't sterilized properly or changed between patients.
"Making sure that scope is clean is simple, like washing your hands," said Representative Phil Roe, (R) Tennessee.
"No one understands how that occurred." said John D. Daigh Jr., Assistant Inspector General for Healthcare Inspections, Veterans Affairs.
Now, the V.A's inspector generals have done surprise checks at 42 other V.A. facilities and found one in eight aren't complying with the manufacturers' sterilizing instructions. Half couldn't even prove the employees involved are competent.
"Your competency levels should not be this low - they should be higher because they've been given notice there's a problem!" Representative Steve Buyer, (R) Indiana explained.
The V.A. says they're fixing the problem with new procedures and training not just for endoscopes but for all medical equipment.
"We should have competency on every employee, and that is our goal. We need to do better on this, and we will," said William E. Duncan, Associate Deputy Under Secretary for Health for Quality and Safety, Veterans Affairs.
But how soon?
"If a veteran walks into a hospital in Florida, Seattle, anywhere. Can they be assured their health will not be compromised?" asked Representative Kendrick Meek, (D) Florida.
The V.A. says 'Yes', but Michael Priest isn't so sure. "This is not very good care," he lamented.