VA Vows Quick Response to DC VAMC Patient Safety Issues

By Sandra Basu

Ground crew at DCVAMC prepare facility for spring. VA photo

WASHINGTON — VA Secretary David Shulkin vowed last month that his agency will “act as rapidly as possible” to hold accountable those responsible for “serious and troubling deficiencies” at the DC VAMC.

“We are focused clearly on accountability. No leader or other employee stands above the paramount concern of ensuring the safety of our veterans,” Shulkin said at a news conference last month about a VA Office of Inspector General (OIG) report.

In an unusual action, the VA OIG released an interim report maintaining that problems it identified at the DC VAMC places patients at “unnecessary risk.”

Some of the problems detailed included:

  • No effective inventory system for managing the availability of medical equipment and supplies used for patient care;
  • No effective system to ensure that supplies and equipment that were subject to patient safety recalls were not used on patients;
  • 18 of the 25 sterile satellite storage areas for supplies were dirty.

“Although our work is continuing, we believed it important to publish this Interim Summary Report given the exigent nature of the issues we have preliminarily identified and the lack of confidence in VHA to adequately and timely fix the root causes of these issues,” the VA OIG explained in a statement.

The report also stated that at least some of the issues “have been known to the Veterans Health Administration senior management for some time without effective remediation.”

The VA OIG review was triggered by a complaint that described equipment and supply issues at the VAMC “sufficient to potentially compromise patient safety,” according to the report. Specifically, among the problems that VA IG observed or documented included that the medical center ran out of bloodlines for dialysis patients on the second shift on March 15, 2017.

“They were able to provide dialysis services to those patients only because staff borrowed bloodlines from a private hospital,” the report pointed out.

Another example of a serious problem was that, on March 29, a nurse emailed the patient safety manager, reporting that, during an acute episode, she needed to provide oxygen to a patient.

“The floor was out of oxygen nasal cannulas (tubing that fits into a patient’s nose and provides oxygen). The nurse was able to use one found on the crash cart but reported the shortage as a risk to patient safety,” the report explained.

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  1. Mark McConnell says:

    Healthcare is an area where we see sick and very sick people. In fact, many are gravely infected. If a “violation” consists of taking a perfectly useful oxygen cannula from a “crash cart” (most of which are never used} is that really something that truly impacts patients? Or is it simply a violation of some administrative code? As to “sterile areas being dirty”: most “sterile” products I use in clinic are for patients who have infected wounds: do I need to use a sterile q-tip to debride an infected wound?

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