VA Patients In ‘Imminent Danger’ at D.C. VA Hospital Per Interim Investigation

Many have wondered if issues have improved within the Department of Veterans Affairs since David Shulkin was appointed by President Donald Trump as VA Secretary.

While it may still be too early to tell if there has been an improvement overall, the VA inspector general’s recent finding that patients at the Department of Veterans Affairs Medical Center in Washington, D.C. were in “imminent danger” isn’t a good sign.

In a rare preliminary report this week, the VA inspector general found several disturbing issues in the D.C. VA hospital as follows:

Recently, “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.”

The last time an interim report similar to this was issued was January 2015.

At that time, it was discovered there were lapses in urology care at the Phoenix VA which were putting patients at risk and were endangering patients and required “immediate attention.”

VA Inspector General Michael Missal wrote about his current report:

“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.”

It has been reported that the VA took quick action to correct the problems on March 30 after the inspector general notified the VA concerning the issues in D.C.

However, Missal indicated that such actions were:

“short term and potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues identified.
Further, shortages of medical equipment and supplies continued to occur…, confirming that problems persisted despite these measures.”

The inspector general’s report was issued on Wednesday. The VA took immediate action by relieving Brian Hawkins of his duties and placing him on administrative duty.

Certainly, the actions were a change from those the public has seen in the past under VA Secretary Robert McDonald and others.

The VA issued the following statement after Hawkins was removed:

“The department considers this an urgent patient-safety issue. 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 accordance with the law.”

The most recent investigation began when an anonymous complaint was filed on March 21. Eventually, the investigation led to the discovery of:

“194 reports that patient safety has been compromised because of insufficient equipment.
Among the findings:
• In February 2016, a tray used in repairing jaw fractures was removed from the hospital because of an outstanding invoice to a vendor.
In April 2016, four prostate biopsies had to be canceled because there were no tools to extract the tissue sample.
In June 2016, the hospital found one of its surgeons had used expired equipment during a procedure
In 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

So far it has not been determined if any patients were actually harmed but that is yet to be determined.

The inspector general’s statement indicates that information will be forthcoming in a final report:

“The OIG’s work is continuing and will include an assessment of whether patient harm has resulted from any of these inventory practices in its final report on the Medical Center.”

Shulkin appears to welcome “transparency” into the VA and has recently launched a new website that will inform the public about how care at VA hospitals stacks up against other hospitals and the national average.

Veterans and the public will surely welcome Shulkin’s latest steps to fix the VA.