WASHINGTON—Disturbing incidents involving VA facilities have been in the headlines recently, including a nursing home patient in Atlanta who was severely bitten by ants, a VA pathologist in Arkansas whose abuse of alcohol allegedly caused him to misdiagnose thousands of patients over 11 years and a string of deaths at the Clarksburg, WV, three of which have been ruled homicides due to insulin injections.

In testimony before the House VA Oversight Subcommittee, high-ranking VHA officials addressed those situations where veterans were injured or died due to poor facility management or clinician negligence. They characterized the situations as “isolated” and caused by “a few flawed staff” and not an indication of a systemwide problem.

Legislators expressed concerns, however, that, while those incidents might be isolated, systemic issues at VA that allow poor performing clinicians to practice medicine far longer than they should. Those assertions were backed up by VA oversight agencies.

A recent VA Office of the Inspector General report was used as a prime example of VA’s inability to deal with clinicians who are putting patients in danger. The report details a case involving an ophthalmologist working at a VA facility in VISN 10, which covers Michigan, Indiana and Ohio. The report does not specify the facility or reveal the clinician’s name.

The ophthalmologist began performing cataract surgeries in February of 2017. Within a few months, facility leaders were informed that, during procedures, the surgeon seemed to lack confidence and that procedures were taking excessively long, with a 30-minute surgery lasting as long as two hours.

That is in contrast to most surgeons being able to complete six to eight cataract surgeries during a scheduled operating room day. After a year, this surgeon was only able to complete two in a day. An attempt by the chief of surgery to increase that number by one each month beginning in April 2017 resulted in reports of increased complications and suboptimal outcomes, and the surgeon’s assigned cases were decreased again. More complex cases were referred out to community care providers.

It was not until September 2017 that the chief of surgery requested that one of the facility’s contract ophthalmologists observe the surgeon during cataract surgeries. While the observer’s report found that the results of the surgery fell “within community standards,” OIG investigators later discovered that the criteria the observer used did not actually address the concerns that had been brought forward. For example, the report did not describe the complexity of the cases, how many cases were observed or the time it took to complete them. According to investigators, the chief of surgery appeared to not question the deficiencies of the report, and the ophthalmologist was allowed to continue operating.

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