Veterans Affairs hospitals across the country reported more than 500 incidents last year where patients were gravely injured or died as a result of the care they received.
Data obtained by the WashingtonFree Beacon through the Freedom of Information Act (FOIA) shows 575 “institutional disclosures of adverse events” – the bureaucratic phrase for reporting a serious mistake – at VA hospitals in fiscal year 2013.
According to the Veterans Health Administration ethics handbook, such disclosures are required when “an adverse event has occurred during the patient’s care that resulted in or is reasonably expected to result in death or serious injury.”
Specifically, adverse events are defined by the department as “untoward incidents, diagnostic or therapeutic misadventures, iatrogenic injuries, or other occurrences of harm or potential harm directly associated with care or services provided” by the VA.
How many of the 575 “adverse events” reported last year resulted in patient deaths is unknown. It is also unclear how 2013 compared to previous years. The Free Beacon has filed another FOIA request seeking this information.
“Until VA leaders make a serious attempt to address the department’s widespread and systemic lack of accountability, I fear we’ll only see more of these lapses in care,” Rep. Jeff Miller (R., Fla.), the head of the House Veterans Affairs Committee, said in a statement to the Free Beacon.
“Like other hospital systems, VA isn’t immune from human error – even fatal human error,” Miller said. “But what the department does seem to be immune from is meaningful accountability. Given that these tragic events are part of a pattern of preventable veteran deaths and other patient-safety issues at VA hospitals around the country, it’s well past time for the department to put its employees on notice that anyone who lets patients fall through the cracks will be held fully responsible.”
The VA came under intense scrutiny from Congress and the media this year after whistleblowers revealed thousands of veterans were placed on secret wait lists and dozens died awaiting treatment.
VA Secretary Eric Shinseki resigned earlier this year as a result of the uproar that followed. The department also ordered a nationwide audit of its consulting practices.
Medical privacy laws strictly bar from disclosure the names of patients and other details, making it difficult to document individual cases. However, the data obtained by the Free Beacon gives a broad view of serious mistakes at VA hospitals over the past year.
The Malcom Randall VA Medical Center in Gainesville, Fla., reported 31 “adverse events” during fiscal year 2013, the most of any VA facility.
The VA also confirmed two patients died at North Florida/South Georgia system, where the Gainesville hospital is located, due to delayed cancer screenings.
The system is the busiest in the country, serving roughly 125,000 VA patients per year.
VA hospitals have struggled to handle the flood of new patients in the years following 9/11, especially after the troop drawdowns from Iraq and Afghanistan in recent years.
However, numerous congressional investigations and internal audits by the VA also describe a corrosive work environment, where leadership encouraged staff to cook the books to meet performance standards and where whistleblowers were harshly punished.
Three VA officials in Gainesville were placed on leave this year after an audit by the VA Inspector General found the hospital was using a secret paper list to keep track of appointments.
There were also allegations that surgeons were not allowed to perform certain operating room procedures to avoid increased mortality rates, and that patients with a high mortality risk were sent to a local hospital. However, the VA Inspector General said in a report Monday it could not substantiate those claims.
The Malcom Randall VA Medical Center did not return requests for comment.
The VA Pittsburgh Healthcare System reported 26 disclosures in fiscal year 2013.
CBS reported earlier this year that the Pittsburgh VA failed to warn patients of a fatal Legionnaires’ Disease outbreak. At least six veterans died and 16 fell ill from February 2011 to November 2012 as a result of the outbreak, while leadership tried to insulate the hospital from the Centers for Disease Control and congressional investigations.
A Pittsburgh VA official later falsely testified before Congress that the outbreak was the result of the city’s water treatment, when in fact the hospital had known for more than a year that it was caused by human error.
The Charlie Norwood VA Medical Center in Augusta, Ga., reported 14 “adverse events” during fiscal year 2013, and three cancer patients died as a result of delayed screenings over the past two years.
According to a 2012 report from the VA Inspector General’s Office, five patients died or sustained serious injury as a result of mismanagement between 2007 and 2010, and more than 4,500 gastrointestinal endoscopy consults went unresolved.
A recent VA audit reported that 26 new patients in Augusta had to wait at least 90 days for an appointment. Additionally, 133 veterans were not scheduled for an appointment despite requesting one in the past 10 years.
Since then, Augusta officials say they have reduced the number of veterans waiting at least 90 days for an appointment from 26 patients to two.
Acting VA Secretary Sloan Gibson toured the center last week, as part of a national tour of VA facilities, and said much of the scheduling problems were due to staff shortages.
“It should not take so darn long to hire someone,” Gibson said. “We need to make sure we’re talking to staff more frequently and understanding their needs. The employees here truly care.”
There are currently four open federal investigations into whistleblower retaliation at the hospital.
In Columbia, S.C., the William Jennings Bryan Dorn veterans hospital reported 13 serious mistakes in patient care during fiscal year 2013. There have been six total deaths since 1999 due to delayed cancer screenings, according to the VA report.
A February report by the VA Inspector General found the Dorn hospital faced staffing and equipment shortages that led to delays. The report also noted that Dorn ranked 127th out of 128 VA facilities in health care-associated infections during 2013.
In response, the Dorn VA hospital agreed said it was immediately taking steps to fix the problems.
The hospital reported four more “institutional disclosures” in the second quarter of fiscal year 2014.
The Dorn VA hospital did not return requests for comment.
Wrongful death payments
Another measure of how patients are killed or gravely injured due to VA mistakes is wrongful death payments.
The Malcom Randall VA Medical Center in Gainesville has made more than $5 million in wrongful death payments in the years since 9/11, according to data from the Center for Investigative Reporting.
Overall, the Department of Veterans Affairs has paid out more than $200 million in wrongful death payments since then. But it is also an incomplete look at the problem.
According to the Center for Investigative Reporting, “independent legal analysts say the nearly 1,000 wrongful death payments in the decade after 9/11 represent a small percentage of the veterans who have died because of malpractice by the Department of Veterans Affairs.”
Eddie Creed, a Seattle-area jazz musician, died in 2012 at a VA facility after a medical device malfunctioned and emptied a lethal dose of morphine into his body. The medical device had been recalled a month earlier.
Creed’s death certificate said he was killed by throat cancer.
The VA refused to release the details of an internal investigation into the accident to Creed’s family until after local news outlet KUOW investigated the incident.
The VA Inspector General found that the Dorn VA hospital failed to peer-review numerous patient deaths – many of them shortly after surgeries – that met the criteria for review. The hospital has since gone back and reviewed those deaths.
The Department of Veterans Affairs did not immediately return a request for comment for this article.
A woman in Kentucky is demanding answers from a local VA hospital after she claims her husband was erroneously pronounced dead.
According to Jennifer Dunn, doctors at the Lexington VA Hospital assured her last week that her husband, Danny Dunn, was no longer among the living.
The wife was given her husband’s time of death, but when she went into his room to bid a final farewell, she found Mr Dunn with a strong heart rate and blood pressure.
It all started last Thursday morning when 46-year-old Danny Dunn, an U.S. Army veteran, was discovered unconscious by his wife in their Central Kentucky home.
The former soldier was rushed to a hospital in Harrodsburg and was later airlifted to the VA Hospital in Lexington, where medical personnel pronounced him dead.
‘I said, “Are ya’ll sure he’s gone?” and they said, “There’s no pulse, ma’am, he’s gone,”‘ Jennifer Dunn told LEX18.
In accordance with her husband’s end-of-life wishes, Mrs Dunn made the decision to take him off life support, but she quickly discovered that Danny still had vital signs.
As of Monday, the 46-year-old veteran was very much alive, and according to his wife, apparently growing stronger.
‘He squeezed my hand when I asked him to,’ she said. ‘He opened his eyes when I asked him to. And he grabbed my hand.’
The Dunn family now want the ailing husband and father transferred to another hospital for treatment.
The VA facility in Lexington released a general statement to the local TV station, which read in part: ‘Veterans can have confidence that our staff of dedicated and professional providers is committed to working with them and their families to honor their wishes and support their needs.’
But the Dunns are far from satisfied with the hospital’s response to the near-fatal blunder.
‘They said his soul was gone and that he wasn’t living no more,’ said Dunn’s son, Tyler. ‘That he was gone long before we got him there… I mean we’re just looking for answers and they won’t give us any.’
This case is yet another black eye for the beleaguered VA system, which has faced public scrutiny in connection to explosive allegations of poor – and at times non-existent – medical care offered to servicemen and women.
The VA’s inspector general has confirmed that at least 35 veterans died while awaiting appointments at the agency’s Phoenix medical center alone.
The resulting election-year firestorm forced VA Secretary Eric Shinseki to resign in May. A half-dozen other VA officials have resigned or retired since then.
More than 8million of the nation’s 21million veterans are now enrolled in VA health care, although only about 6.5million seek VA treatment every year.