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VA Vows Quick Response to DC VAMC Patient Safety Issues

by U.S. Medicine

May 9, 2017

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.

Addressing Issues

Shulkin said he became aware of the issues only when the IG brought them to him, although the regional offices were aware of some supply issues and had a team in place to address it since March.

“When I became aware that veterans were at risk, that is when we took immediate action,” Shulkin said.

In the wake of the report, VA replaced the DC VAMC director with the acting medical center director. Then, hours later, VA instead appointed retired Army Col. Lawrence Connell as the acting medical center director.

Shulkin explained they appointed Connell as director because “he wanted someone from his personal staff, someone from outside the organization” who understood his intentions.

Shulkin also said the agency appreciated that VA OIG raised the concerns and that he believes VA has “the ability to fix these issues.”

He said officials would “focus immediately on the items the inspector general listed in its report and look to address other concerns as we uncover those that are not in the report.”

IG Report Reaction

House Committee on Veterans’ Affairs ranking member Rep. Tim Walz (D-MN) called the safety issues at the hospital “outrageous and unacceptable.”

“When you have systemic failure on this level, management must be held accountable,” Walz said. “The House Veterans’ Affairs committee must conduct oversight on this critical issue without delay.”

David Cox Sr., national president of the American Federation of Government Employees, said, however, that “this is not a moment to score political points.”

“It’s a moment to get to work to solve these issues immediately,” Cox emphasized. “The very best problem-solvers and the most ardent allies of veterans are the VA’s frontline workers who care for veterans despite management failures.”

American Legion National Commander Charles E. Schmidt, meanwhile, praised VA Secretary David Shulkin for replacing the medical center director. “We believe this is a positive step in increasing accountability, and we are hopeful that the new leadership will be able to resolve these issues quickly,” Schmidt said.

The organization also called on President Donald Trump and Shulkin “to ensure the safe and efficient management of all VA facilities and on Congress to properly fund the Department of Veterans Affairs so that the needs of our nation’s veterans can be fully addressed.”


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