Review of Ear, Nose, and Throat Surgery-Related Sterile Processing Services Concerns at the Michael E. DeBakey VA Medical Center in Houston, Texas

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Michael E. DeBakey VA Medical Center (facility) to evaluate concerns regarding Sterile Processing Services (SPS) deficiencies and their impact on ear, nose, and throat surgeries. The inspection was initiated following a complaint alleging that SPS leaders did not effectively manage reusable medical device inventory, resulting in broken and missing instruments and subsequent procedure cancellations.

Veterans Health Administration requires SPS lines to use a specific electronic tracking and data management system. The facility used the CensiTrac system, but staff did not use all capabilities. Instruments were not consistently etched for tracking or scanned into CensiTrac. SPS staff reported sending incomplete instrument sets with count sheets identifying missing instruments. Operative care line staff reported the count sheets were inaccurate and identified instruments as present when missing.

The chief of SPS position remained without a permanent leader for almost three years, and the assistant chief role remained unfilled since October 2023. The position responsible for overseeing SPS quality and process improvement was held by acting individuals until permanently filled in August 2025. Leadership vacancies and turnover may have prevented effective oversight of inventory management.

Inspectors found procedure cancellations were often due to broken, missing, or contaminated devices. Two patients received anesthesia or other medications before cancellation. A required issue brief was not initiated for one cancellation, and issue brief action plans were not presented to the reusable medical device committee. The inspection resulted in three recommendations to the Facility Director. 

In response to the recommendations, the Facility Director reported ongoing recruitment of an SPS assistant chief and review of SPS inventory management and oversight processes, and described a process for tracking issue briefs related to surgery cancellations.