VA Oversaw Preventable Veteran Deaths

The Obama administration’s Department of Veterans Affairs (VA) oversaw three preventable veteran deaths due to errors and negligence at a VA hospital in Memphis, according to a new VA Office of Inspector General (OIG) report and other documents.

The damning OIG report comes just weeks after the VA admitted that six veteran deaths were linked to delayed cancer screenings at a VA facility in South Carolina and a report that appointment delays led to veterans being harmed in Augusta, Fa.  VA, which spent more than $3.5 million on furniture on the last day of fiscal year 2013, also awarded five-figure bonus to the executive who oversaw the Memphis facility, even as it acknowledged that problems were cropping up.

Memphis VA Medical Center saw three patient deaths in its emergency department that prompted an anonymous phone call to the OIG in October of 2012.  In January 2013, the OIG found the “Facility response to the deaths considered inadequate” and a review was initiated with a May 29-31 site visit.

“We substantiated that a patient was administered a medication in spite of documented drug allergy, and had a fatal reaction. Another patient was found unresponsive after being administered multiple sedating medications. A third patient had a critically high blood pressure that was not managed aggressively, and experienced bleeding in the brain approximately 5 hours after presenting to the ED,” according the OIG report’s conclusions.

“We found that the facility took actions as required by Veterans Health Administration in response to the unexpected patient deaths, but noted that implementation of action plans developed through RCAs was delayed and incomplete. We found inadequate monitoring capabilities for patients in some ED rooms, an issue identified during our site visit last year. We also found that nursing ED-specific competency assessments had not been completed,” the report’s conclusion continued.

In each case, erroneous actions by hospital staff contributed to patient deaths.

“Hand written orders for Patient 1 did not comply with the facility’s requirement that all provider orders and patient care be documented in the EHR {Electronic Health Record}. Since the orders were not entered into the EHR, systems in place to prevent medication errors were bypassed,” according to the report.

“When we interviewed staff, we did not get a clear response about what happened with Patient 2’s oxygen saturation monitor. One staff member believed that the monitor slipped off the patient’s finger and no one heard and/or responded to the alarm. We were unable to establish whether or not the alarm sounded, but we were told that tests done on the monitor after the event showed the alarm was functional. Since the patient was physically located away from the main ED, it is possible that staff would not have heard the alarm.”

“Patient 3 had preexisting hypertension and multiple comorbidities, but his deterioration may have been prevented if appropriate antihypertensive medications had been given more aggressively,” according to the report. The facility director concurred with all four recommendations for improvement laid out by the OIG.

“Like other hospital systems, VA isn’t immune from human error – even fatal human error. But what the department does seem to be immune from is meaningful accountability. Given that these tragic events are part of a pattern of preventable veteran deaths and other patient-safety issues at VA hospitals around the country, it’s well past time for the department to put its employees on notice that anyone who lets patients fall through the cracks will be held fully responsible,” Rep. Jeff Miller, chairman of the House Committee on Veterans Affairs said in a statement.

“It’s the only way to ensure veterans get the medical care they deserve and prevent heartbreaking events like this from happening in the future. Until VA leaders make a serious attempt to address the department’s widespread and systemic lack of accountability, I fear we’ll only see more of these lapses in care,” Miller said.

These recent events were not the first time that the Memphis emergency room came under scrutiny. The Memphis hospital’s problems have been considered severe for quite some time, with problems such as leaving patients left on stretchers in hallways waiting to be admitted and length of stay being far below the VHA standard.

“We substantiated that management was aware of these issues but had not taken adequate action for resolution. …The potential for harm exists, however, if the Emergency Department flow problems continue. Boarding patients awaiting admission for lengthy periods’… enhances the potential for errors, delays in treatment, and diminished quality of care,” according to an August 15, 2012 OIG report.

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