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Report: 3 more VA patients die from negligence

Oct. 25, 2013 - 06:00AM   |  
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Three more patients have died in a Veterans Affairs Medical Center as a result of negligence — the latest in a series of preventable deaths that have occurred at VA facilities nationwide.

An internal VA investigation released Wednesday found that three patients died last year after receiving inadequate or improper care at the Memphis VA Medical Center emergency room, including one who had a fatal reaction to a medication that he was known to be allergic to.

Another was left alone and unmonitored after being given intravenous narcotics, tranquilizers and an anti-inflammatory for severe back pain. That patient was found unresponsive and not breathing 45 minutes later and was resuscitated but died 13 days later without ever emerging from a coma.

The third died after spending hours in the ER receiving inadequate treatment for high blood pressure.

These are the latest in a string of deaths at VA hospitals that the department’s Inspector General has attributed to improper care, poor medical practice or bad procedures.

From 2011 to 2012, 21 patients at the VA Pittsburgh Healthcare System contracted Legionnaires’ disease and five died, even though leaders were aware of the contamination risk.

Three mental health patients at the Atlanta VA died in 2011 and 2012, including one who was not properly monitored and killed himself in a hospital bathroom.

At the VA Medical Center Dallas, families of patients say chronic understaffing and poor practices have lead to deaths; at the G.V. Sonny Montgomery VA Medical Center in Jackson, Miss., five whistle-blower complaints have been filed for problems ranging from nurses improperly prescribing narcotics and a radiologist jeopardizing patient safety by misreading images.

At the Bill Hefner VA Medical Center in Salisbury, N.C., surgeons performed procedures without operating room priveleges, while at the Miami VA Healthcare System, a veteran committed “suicide by cop” a day after being improperly discharged.

During a hearing in Pittsburgh on Sept. 9, VA Undersecretary for Health Dr. Robert Petzel said VA is committed to “providing the highest quality of care” and said the problems are not systemic.

“While no health care system can be made entirely free from inherit risks, when adverse incidents do occur, VA studies them to fully understand what has happened, how it happened and how the system allowed it to happen,” Petzel said.

In the Memphis cases, the VA IG found that physicians conducted reviews of the three deaths to “identify and correct systemic factors ... that post a threat to patient safety,” but the hospital has yet to implement all recommendations.

But a VA official said Saturday that the hospital has taken steps to ensure similar events don’t occur again, including following up on findings by an internal hospital review.

According to VA spokesman Mark Ballasteros, the physician involved in two of the three cases no longer works at the facility.

In addition, the main ER now places all patients on a heart monitor, is installing an additional cardiac monitoring system and employs a nurse educator to ensure that the nursing staff has the training and certification needed to work in an ER.

“The Memphis VA Medical Center is committed to providing veterans the best care anywhere and our goal is to provide that care in a safe environment,” Ballasteros said. “Memphis VA takes this issue very seriously.”

Lawmakers have joined forces to press VA to hold hospital leaders accountable and explain why the department continues to award performance bonuses to medical center directors when preventable deaths occur on their watch.

Rep. Mike Doyle, D-Pa., whose district includes Pittsburgh, has urged VA leaders to take action, especially in Pittsburgh, where a criminal investigation is ongoing.

“Something clearly went amiss in these cities, and we need to get to the bottom of it to make sure it never happens again,” Doyle said at the September hearing in Pittsburgh.

And Rep. Jeff Miller, R-Fla., chairman of the House Veterans’ Affairs Committee, has written President Obama asking him to address the the “management, oversight and leadership failures that are pervasive throughout the department.”

Miller said Friday that VA must do more to safeguard its patients.

“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,” Miller said. “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.”

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