The Department of Veteran Affairs Office of Inspector General issued a report on March 7, 2018 entitled, “Critical Deficiencies at the Washington DC VA Medical Center” (“Report”) in which it found “widespread and formidable inadequacies in many essential functions at the [Washington DC VA] Medical Center that contributed to the deficiencies described in this report, including:
• The inability to consistently provide supplies, equipment, and instruments to patient care areas when needed;
• Ineffective sterile processing contributing to delays or postponements of procedures due to unavailable usable instruments;
• The lack of consistently clean storage areas for medical supplies and equipment;
• The failure to accurately and consistently track and trend patient safety events;
• Excessive vacancies in leadership positions and other pervasive staffing issues across multiple departments, including Logistics, Prosthetics, Sterile Processing,and Environmental Management Services;
• More than 10,000 open and pending prosthetic and sensory aid consults as of March 31, 2017, causing some patients to wait months for needed items;
• Financial and inventory systems producing inadequate data, lacking effective internal controls, and yielding no assurances that funds were appropriately expended;
• Approximately $92 million in supplies and equipment being charged to purchase cards over a two-year period without proper controls to ensure the purchases were necessary and cost-effective;
• Underutilization of the prime vendor contract that was designed to purchase supplies at more favorable prices;
• More than 500,000 noninventoried items maintained in an inadequately secured warehouse; and
• Patient protected health information (PHI) and personally identifiable information (PII) stored in unsecured areas.
The Report found that “[t]he dysfunctions identified at the Medical Center were prevalent and deeply intertwined. They could not be attributed to any single individual, but rather were the result of inadequate actions and accountability across many services and positions. The OIG encountered a culture of complacency among VA and Veterans Health Administration (VHA) leaders at multiple levels who failed to address previously identified serious issues with a sense of urgency or purpose.”
Significantly, the Report stated “Despite these significant issues, the OIG did not find evidence of patient deaths or other adverse clinical outcomes resulting from these deficiencies” but further stated “Although the OIG did not identify patients who suffered death or other adverse clinical outcomes as a result of the identified problems, veterans were put at risk because important supplies and instruments were not consistently available in patient care areas” including:
• Needless hospitalizations (with attendant risks) occurred when patients’ procedures were canceled following their admission, sometimes for overnight stays, because items could not be accessed in time for scheduled surgeries;
• Patients received unnecessary anesthesia when scheduled procedures were delayed to track down or borrow items (prolonging anesthesia) or rescheduled (requiring a second round of anesthesia);
• Surgeons sometimes relied on instruments that were available rather than those they were most comfortable in using, which resulted in not being able to use preferred techniques;
• More than 300 patient safety events involved a reported problem with supplies, instruments, or equipment from January 1, 2014, through September 6, 2016, with more than 100 of these events not reported to the VHA National Center for Patient Safety as required by VHA policy; and,
• The Patient Safety Manager failed to accurately and effectively track and trend patient safety events, resulting in the Medical Center missing opportunities to conduct Aggregated Reviews of supply, instrument, or equipment issues to identify and correct problems.”
The Report concluded: “While the findings and recommendations made in this report should improve patient safety and the timeliness and quality of services at the Medical Center, leaders of all VHA healthcare facilities could benefit from closely reviewing the findings and recommendations to help identify and address any similar problems in their facilities as well.”
If you or a loved one received medical care through the VA that was negligent, or the VA negligently failed to provide necessary medical care in a timely fashion, you should promptly find a local medical malpractice lawyer in your U.S. state who handles VA medical malpractice claims, who may investigate your VA medical malpractice claim for you and represent you or your loved one in a medical malpractice claim involving the VA, if appropriate.
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