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April 14, 2017

'Highest levels of chaos' threaten care at VA hospital, report finds

Daily Briefing

    Conditions at a Washington, D.C., Veterans Affairs (VA) medical center might have endangered patients' lives, according to a preliminary VA Office of Inspector General (OIG) report released Wednesday.

    The medical center serves about 98,000 veterans in the D.C.-area. OIG launched the investigation after receiving an anonymous compliant on March 21.


    Overall, OIG found that the medical center does not have an effective inventory system. OIG said there have been 194 reports over the past three years that patient safety had been compromised at the center because of insufficient equipment. Further, OIG found that the center in recent weeks has run out of:

    • Bone material for knee replacement surgeries;
    • Compression devices that help prevent blood clots;
    • Tubes used for kidney dialysis;
    • Ultrasound probes used to track patients' blood flow; and
    • Vascular patches used to seal blood vessels during surgery.

    According to OIG, physicians continued to provide services to patients that required the missing supplies in some instances, choosing to either not use the missing equipment or borrow the equipment from nearby health care centers. In other instances, medical procedures were delayed or canceled, OIG found.

    OIG also found instances in which the facility could not verify whether the supplies physicians were using had been recalled or expired. Further, OIG inspected 25 sterile storage areas at the center and found that 18 were unclean.

    OIG said senior VA officials knew about the inventory system issue for months, but did not address the problem. OIG in the report also noted that the medical center had several senior-level staff positions unfilled for years, including a chief of logistics and a head nurse.

    VA Inspector General Michael Missal said the issues have created "the highest levels of chaos" at the medical center and "unnecessary risk" for patients. He said OIG has not yet determined whether any patients were harmed, but that his office will continue investigating the center.

    The 10 biggest patient-safety issues, according to ECRI

    However, Missal said officials "believed it appropriate to publish" the preliminary report "given the exigent nature of the issues we have preliminarily identified and the lack of confidence in [the Veterans Health Administration] adequately and timely fixing the root causes of these issues."

    VA, House panel respond

    According to USA Today, OIG informed VA officials about the issues identified in the report on March 30, and officials then created an incident command center and sent logistics specialists, managers, and technicians to the hospital to address the problems.

    Missal said those efforts are "short term, and potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues identified," adding that "shortages of medical equipment and supplies continued to occur" despite those measures.

    Further, VA on Wednesday said immediately after the issues were brought to light the medical center's director, Brian Hawkins, was removed from the position and placed on administrative duty. "The department considers this an urgent patient-safety issue," VA said, adding that it is "conducting a swift and comprehensive review into these findings." VA continued, "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."

    VA on Thursday announced that retired Army Col. Lawrence Connell would take over as the medical center's acting director.

    Meanwhile, a spokesperson for the House Veterans' Affairs Committee on Thursday said the panel also is investigating the medical center. Rep. Phil Roe (R-Tenn.), the committee's chair, said, "When our nation's veterans go to a VA facility, they deserve to be treated with the highest quality care—not have their health and safety put at-risk due to a facility's lack of oversight" (Slack, USA Today, 4/13; Davis, "D.C. Politics," Washington Post, 4/13; Devine, CNN, 4/12; MacFarlane/Stabley, NBC4, 4/12; Wentling, Stars and Stripes, 4/12).

    Next steps: Reducing hospital mortality with the help of an EMR

    Electronic medical records (EMR) have a role to play in mortality reduction. Computerized practitioner order entry (CPOE) and electronic order sets are the key EMR capabilities that can help reduce hospital mortality, but changes in process, culture, and individual behavior are also necessary.

    In this report, we present six hospital case studies to illustrate the impact of EMR on mortality, identify the mechanisms by which EMRs could help reduce hospital mortality, and zero in on the specific functionality that might have the greatest impact.

    Download the report

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