#VAFail – Patients are at “unnecessary risk” at DC VA medical center
Dirty sterile equipment storage areas. Insufficient supplies. Millions of dollars of missing equipment. Unfilled critical staff positions. That’s what a team from the VA Office of Inspector General (OIG) found when they investigated an anonymous complaint at the Washington, DC, VA Medical Center last month.
The situation was so bad, the team put together an interim report detailing what they called “serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk.” The OIG says they took the unusual step of issuing a preliminary report because of the severity of the conditions and “the lack of confidence in VHA adequately and timely fixing the root causes of these issues.”
Among the findings:
- Of the 25 sterile storage areas at the facility, 18 were dirty and 5 mixed clean equipment with dirty supplies. Some were also used for offices or patient care spaces.
- The Medical Center regularly ran out of necessary supplies, including bloodlines for dialysis and oxygen tubing. In one case, the center was out of a device used to prevent blood clots in the legs during surgery, but doctors proceeded with the operation anyways. Since 2014, the Medical Center has filed 194 patient safety reports about unavailable equipment or supplies.
- The Medical Center had no system to track whether the supplies they did have were expired or recalled for safety issues. Instead, staffers used email, which the report says was “prone to human error” and resulted in a surgeon using expired equipment on a patient.
- Administrators also didn’t conduct the necessary inventory checks to track equipment and find out if any was missing. In the past year, almost 30,000 items worth over $150 million were unaccounted for.
- Numerous senior staff positions have gone unfilled—some for over a year—including Associate Medical Center Director, Chief of Radiology, and Chief of Human Resources.
The report says staffers from VA Central Office have known about the situation since January, yet “significant equipment and supply shortages continued, placing patients at risk.” After the OIG team briefed VA administrators last month, they added extra temporary staffers to try to fix the problem, but the OIG team’s report says they’re doubtful these measures will help.
The DC VA director has been removed from his position, but thanks to current VA policies he has been reassigned to administrative duties rather than fired for incompetence. The VA has brought in a temporary director from outside the facility to fill in, which is good news, but structural reform is still sorely needed.
This is just the latest example of the toxic culture of incompetence we’ve seen time and time again at the VA. The fact that this can happen at a Medical Center in DC, right under the nose of administrators, is further proof that major changes are long overdue. VA Secretary Shulkin himself has called for Congress to pass legislation that would give him the authority to fire bad employees. The Senate needs to act swiftly and pass the VA Accountability First Act so Secretary Shulkin can begin to clean up this agency.
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