Missed opportunity

Sunday, March 9, 2008 | 3:08 a.m.

There is a possibility that unsafe procedures at the Endoscopy Center of Southern Nevada — procedures that have placed 40,000 people at risk for three potentially fatal blood diseases — could have been discovered during scheduled state inspections.

No one will ever know for sure, however, because the inspections never took place.

The Nevada agency in charge of inspecting medical facilities — the Nevada State Health Division’s Licensure and Certification Bureau — issued a memo in 2001 promising complete inspections every three years. But as reported Thursday by Las Vegas Sun reporter David McGrath Schwartz, the agency did not follow its own schedule.

The Endoscopy Center was not fully inspected in 2004, nor was it fully inspected in 2007. Bureau inspectors have visited the Endoscopy Center over the past several years, but only to review specific complaints.

Complete inspections, which could have revealed the employees’ routine violations of standard procedures for using syringes and medicine vials while administering anesthesia, were simply not conducted.

A full inspection was finally conducted in early January, after a hepatitis C cluster was traced back to the center. An ensuing, and ongoing, investigation revealed that patients since 2004 could have been exposed to the blood of another patient. Now, 40,000 former clients of the center need to have their blood tested periodically for hepatitis C, hepatitis B and HIV.

The bureau cited a lack of resources in explaining why it did not follow through on its inspection schedule. The Associated Press reported Friday that Gov. Jim Gibbons, in keeping with his campaign pledge to not raise taxes or fees, last year cut 10 new inspector positions from the bureau’s proposed budget. Ultimately the Legislature did approve six new inspector positions.

With assistance from federal agencies, the state is now rushing to observe medical procedures at all outpatient surgical centers. For the long term, however, state government must ensure that full inspections take place more frequently — and on schedule.