#VAFAIL – Michigan VA Unsafe Blood Transfusion Practices Prove Near-Fatal for Veteran
A recent report of negligence and neglect from the Battle Creek VA Medical Center in Michigan highlights the urgent need for VA accountability.
Two years ago, the VA Office of Inspector General (OIG) responded to a complaint involving a veteran who received an unsafe blood transfusion at Battle Creek.
The caregiver had full access to the patient’s medical records and chest X-rays, which showed existing medical issues that should have prevented the veteran from receiving a blood transfusion in the first place. Instead of double-checking these records, negligence nearly killed the patient.
The blood transfusion worsened the veteran’s existing condition, leading to a near-fatal circulatory overload.
The OIG report also detailed an attempted cover-up. The medical center’s policy requires that providers report all blood transfusion-related reactions to the Blood Usage Review Committee – a group that analyzes blood-related incidents and works to prevent them from recurring. Yet the care giver and supervisor failed to report the veteran’s adverse reaction.
The same physician who supervised and ordered the blood transfusion in question also sits as the Transfusion Officer on the Blood Usage Review Committee.
Additional findings from the OIG show the Peer Review Committee’s failure to follow Veterans Health Administration peer review procedures.
These examples from the Battle Creek Veterans Affairs Medical Center highlight the inexcusable lack of quality care standards and culture of negligence at the VA.
It’s time for real accountability. We can start by passing the VA Accountability and Whistleblower Protection Act. Urge your lawmakers to support VA reform and learn more here.