Staffers at a Florida-based Veterans Affairs hospital say leadership ignored a medical equipment recall for weeks — even after a patient’s life was endangered — despite repeated warnings their inaction violated health and safety norms.
But officials at the James A. Haley Veterans' Hospital in Tampa said their week they have removed all of the faulty items without any harm to patients, dismissing concerns that proper procedures were not followed.
It’s unclear whether the dispute is isolated to the single VA medical center or indicative of larger problems with recall alerts throughout the nation’s veterans hospital system. Department of Veterans Affairs officials in Washington, D.C. referred all questions to local hospital officials.
Investigators found inadequate safety checks, missing security cameras and ignored warnings.
At issue is a July 31 incident where a patient at the Tampa medical center received too much prescribed medication because of what nurses described as malfunctioning IV equipment. Tubing designed to slowly drip out fluids into the patient’s bloodstream instead allowed a rush of medication all at once. In a grievance filed with facility leadership, staff said a medical disaster was avoided only because nurses on duty quickly diagnosed and responded to the problem.
But in a statement to Military Times, hospital leadership said that “no patient harm” occurred and praised medical personnel on staff for quickly identifying the problem. They also said an internal review found no specific equipment malfunctions but did uncover some system parts that were on recall lists.
Dennis McLain, head of the facility’s National Nurses United chapter, said the manufacturer of the IV tubing (BD, headquartered in New Jersey) issued an urgent recall of the equipment two weeks earlier, instructing hospitals to “destroy all products” found in their inventory.
“Since this issue may lead to flow inaccuracies through the pumping cycle process, this may result in an over-infusion and the potential for serious patient injury or death, depending on the type of medication that is being delivered,” the July 18 recall notice states.
In the grievance, McClain said the Tampa site continued not only overlooked that notice but also continued to use the faulty tubing for weeks after the July 31 incident, even after the union filed its formal complaints in early August.
Leadership issued a response this week (after Military Times inquiries on the matter) stating that “after speaking with the manufacturer today to ensure compliance with the recall, staff received additional clarification on tubing products affected” and that now “all affected IV tubing found at the facility is being replaced immediately.”
The death is the latest in a string of suicides in public areas on VA campuses.
Identifying the parts is difficult once it is in use, hospital officials said in their response to the union grievance, because they lack clear model numbers and identification markers once taken out of packaging.
But McClain said he is baffled it took more than a month for any action to address a known recall. Union officials have asked the department’s inspector general to look into whether proper procedures were followed.
According to VA policy, all medical equipment recalls are reviewed and posted on a centralized website for physicians and facility administrators. Officials said all of the recalls are monitored for “impact, relevance, and risks to patient care.”
McClain said several nurses who raised concerns about the ignored recall were told that shortages in IV equipment were to blame. In their response to the grievance, VA officials flatly denied that, and said appropriate inventory is available.
They promised a full inspection of all IV equipment at the facility to ensure all of the systems are working properly. Staff members remain doubtful all the recalled equipment has been removed.
“There is no excuse why we waited this whole time,” McCalin said. “They should have dealt with this earlier.”