D.C. patients alerted to dangers at VA
Inspector general cites ‘unnecessary risk’ from shortages of medical supplies
@donovanslack USA TODAY WASHINGTON Conditions are so dangerous at the Department of Veterans Affairs Medical Center in Washington, D.C., that the agency’s chief watchdog issued a rare preliminary report Wednesday to alert patients and other members of the public.
The VA inspector general found that in recent weeks the operating room at the hospital ran out of vascular patches to seal blood vessels and ultrasound probes used to map blood flow.
The facility had to borrow bone material for knee replacement surgeries. And at one point, the hospital ran out of tubes needed for kidney dialysis, so staff had to go to a private-sector hospital and ask for some.
The hospital, which serves more than 98,000 veterans in the nation’s capital, lacks an effective inventory system, the inspector general determined, and senior VA leaders have known about the problem for months and haven’t fixed it. Investigators also inspected 25 sterile storage areas and found 18 were dirty.
“Although our work is continuing, we believed it appropriate to publish this Interim Summary Report given the exigent nature of the issues we have preliminarily identified and the lack of confidence in VHA adequately and timely fixing the root causes of these issues,” VA Inspector General Michael Missal wrote.
The inspector general rarely issues such preliminary findings. The last time appears to have been in January 2015, when lapses in urology care found at the Phoenix VA required “immediate attention.”
The VA set up an incident command center on March 30 when the inspector general notified officials about the problems in Washington; it sent logistics specialists, technicians and managers to fix the problems.
Such actions, Missal said, are “short term and potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues.
“Further, shortages of medical equipment and supplies continued to occur … confirming that problems persisted despite these measures,” he wrote.
After the report’s release Wednesday, the VA issued a statement saying that the medical center director, Brian Hawkins, was relieved from his position and placed on administrative duty immediately.”
“The department considers this an urgent patient-safety issue,” the statement said. “VA is conducting a swift and comprehensive review into these findings. VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in “effective accordance with the law.”
VA Secretary David Shulkin told USA TODAY this week that he welcomes outside oversight with hopes it will help him fix the beleaguered agency.
The inspector general’s investigation, which stemmed from an anonymous complaint, found 194 reports during the past three years that patient safety has been compromised because of insufficient equipment. Among the findings:
February 2016, a tray used in repairing jaw fractures was removed from the hospital because of an outstanding invoice to a vendor.
April 2016, four prostate biopsies were canceled because there were no tools to extract the tissue sample.
June 2016, the hospital found one of its surgeons used expired equipment during a procedure.
March 2017, the facility found chemical strips used to verify equipment sterilization had expired a month earlier, so tests performed on nearly 400 items were not reliable.
Missal said the practices placed patients at “unnecessary risk,” though so far his office has not determined if patients were harmed.