Watchdog warns of 'unnecessary risk' to VA hospital patients in DC

Watchdog warns of 'unnecessary risk' to VA hospital patients in DC
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A government watchdog issued a rare report Wednesday warning patients at the Veterans Affairs Medical Center in Washington, D.C., that they are at "unnecessary risk" due to inventory management and staffing deficiencies.

The VA's Office of Inspector General cited "the exigent nature of the issues we have preliminarily identified and the lack of confidence in [the Veterans Health Administration] adequately and timely fixing the root causes of these issues" in explaining the decision to release the interim report on the facility, which serves 98,000 veterans.

Among the issues identified, the watchdog found that the facility has no effective inventory system for managing medical equipment and supplies; 18 of the 25 sterile satellite storage areas for supplies were dirty when inspected; and there are numerous and critical open senior staff positions that will make it difficult to address challenges.

Those issues have led to canceled surgeries, the use of expired equipment and borrowing equipment from elsewhere, among other incidents, according to the report.

The VA announced Wednesday in response to the report that it is demoting the hospital's director, Brian Hawkins, who has served in the position since 2011.


"The Department of Veterans Affairs thanks the OIG for its quick work reviewing the D.C. VAMC," the VA said in a statement.

"The department considers this an urgent patient-safety issue. Effective immediately, the medical center director has been relieved from his position and temporarily assigned to administrative duties."

The Office of Inspector General said in its report that senior management at the Veterans Health Administration (VHA) has known about the issues “for some time without effective remediation.”

Still, the report says, the office has yet to find “adverse patient outcomes” as a result.

The office received an anonymous tip March 21 and sent its “Rapid Response Team” to the hospital March 29-30 and April 4-6.

The investigation has found 194 patient safety reports since January 2014 due to a lack of available equipment.

For example, in March, the center ran out of bloodlines for dialysis patients on the second shift and could only provide dialysis to those patients after borrowing bloodlines from a private hospital.

Also in March, the facility found expired chemical strips used to show whether equipment has been sterilized, but did not know whether any had been used on 396 items sterilized between the expiration date and when they were found.

In another example, in April, four prostate biopsies were canceled because the hospital was out of the tool needed to extract the tissue.

The VHA has taken several actions since March 30, when the Office of Inspector General first notified it of its findings. Those include setting up an incident command center and temporarily assigning an additional logistics chief, technicians, and Veterans Integrated Service Network staff to the facility.

But the inspector general's report called those steps “short-term and potentially insufficient.”

“Part of OIG’s mission is to monitor the quality of patient care and outcomes for veteran patients who rely on VA for their health care,” Michael Missal, the inspector general, said in a statement.

“When we become aware of deficiencies at VA that place patients at unnecessary risk, we will act immediately and aggressively to address those deficiencies.”

In its statement, the VA said it is reviewing report's findings and will take additional disciplinary actions if appropriate.

"VA is conducting a swift and comprehensive review into these findings," the statement said. "VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law."