Report: Patients ‘at risk’ at DC VA Medical Center
On April 12, 2017 the Veterans Affairs Office of Inspector General (VA OIG) released an interim report outlining significant substandard conditions at the Department of Veterans Affairs Medical Center in the Nation’s Capital.
The inspection was triggered by an anonymous complaint filed by one VA employee, when they wrote in an email that during an acute episode with a patient, they were unable to find necessary supplies in their unit to provide oxygen to the veteran. However, this appears to be only one of the problems that the DC VA Medical Center is facing.
VA OIG preliminary findings include:
- no effective inventory system for managing the availability of medical equipment and supplies used for patient care;
- no effective system to ensure that supplies and equipment that were subject to patient safety recalls were not used on patients;
- 18 of the 25 sterile satellite storage areas for supplies were dirty;
- over $150 million in equipment or supplies had not been inventoried in the past year and therefore had not been accounted for;
- a large warehouse stocked full of non-inventoried equipment, materials and supplies has a lease expiring on April 30, 2017, with no effective plan to move the contents of the warehouse by that date; and
- numerous and critical open senior staff positions that will make prompt remediation of these issues very challenging.
Source: Full VA OIG Report
While these issues are just being brought to light, it’s clear that employees at the DC VA Medical Center were well aware of problems taking place as a result of these conditions.
Just last week, VA staff were forced to halt vascular surgeries because they had run out of patches used during the operations, despite having requested a resupply two weeks earlier.
In addition, the inspector general’s office reported that other surgical operations were ongoing even though the hospital had run out of compression devices to place on patients’ legs to prevent blood clots from forming.
In total, VA OIG report identified 194 patient safety reports relating to the unavailability of equipment or supplies.
In reaction to the report, Veterans Affairs Secretary David Shulkin promised to launch a full scale top-down review of the Medical Center. To start, the facility’s Director, Brian Hawkins has been relieved of his duties and replaced with Lawrence Connell, one of Shulkin’s close VA Advisors. However, this may just be the beginning of disciplinary actions.
In a statement, the VA said it is reviewing report’s findings and will take additional disciplinary actions if appropriate.
“VA is conducting a swift and comprehensive review into these findings,” the statement said. “VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law.”
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