Watchdog: Accountability

Three more veterans die after improper VA medical treatment

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Improper care in the emergency room led to three patient deaths at the Department of Veterans Affairs hospital in Memphis last year, part of a growing pattern of preventable deaths at agency hospitals nationwide.

The latest report from the VA's Inspector General found one of the patients was given medication despite a documented allergy to the drug, and had a fatal reaction.

Another died after being administered multiple medications without proper monitoring, and the third died after delays in getting proper treatment for very high blood pressure, the IG said.

The deaths occurred between April and September 2012.

Recent IG reports have linked patient deaths and infections at other veterans' facilities to improper care, unsafe sanitary practices and poor maintenance.

Those include five deaths from Legionnaires' disease at the VA medical facility in Pittsburgh, four deaths by suicide or drug overdose in Atlanta and six deaths resulting from delayed colon cancer screenings in Columbia, S.C.

James Robinson, who was director of the Memphis facility last year, received a $10,782 merit pay bonus in 2011, but none in 2012, according to documents obtained by the Washington Examiner.

Robinson was replaced earlier this year by C. Diane Knight. VA officials would not give the exact date or say whether Robinson’s departure had anything to do with the three deaths.

Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans' Affairs, said he is fed up with top VA administrators getting bonuses instead of discipline for poor service at their facilities.

“Like other hospital systems, VA isn’t immune from human error — even fatal human error,” Miller told the Examiner. “But what the department does seem to be immune from is meaningful accountability."

The deaths in Memphis are “part of a pattern of preventable veteran deaths and other patient-safety issues at VA hospitals around the country,” Miller said.

“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,” he said.

An August 2012 VA-IG investigation of the Memphis emergency room found unacceptable wait times and other issues. Management was aware of the problems but did not fix them, the IG reported.

“The potential for harm exists, however, if the ED (emergency department) flow problems continue,” the 2012 IG report states. “Boarding patients awaiting admission for lengthy periods enhances the potential for errors, delays in treatment and diminished quality of care.”

In May, the IG returned to the Memphis facility to investigate an anonymous complaint that improper care led to three patient deaths. That investigation found:

– A patient who went to the emergency room with neck and back pain was given medication that triggered an allergic reaction. The patient had disclosed medical allergies and should not have been given the drug. An hour after being sent home, the patient was brought back in an ambulance in full cardiac and respiratory arrest. He died eight days later after the family agreed to discontinue life support.

– A patient was given painkillers, a tranquilizer and anti-nausea medication after complaining of extreme back pain, then was not properly monitored. When a nurse checked on the patient 45 minutes later, he was unresponsive and not breathing. He went into a coma and died 13 days later.

– A patient with multiple medical conditions including diabetes, congestive heart failure and serious renal disease went to the emergency room with shortness of breath and eye pain. He had extremely high blood pressure, but was not treated properly for more than three hours and his condition deteriorated. He died the next day after a CT scan detected bleeding in the brain.

A VA spokeswoman in Memphis released a written statement but referred all questions to the agency’s headquarters in Washington, D.C., which did not respond.

The statement by Dr. Christopher Marino, chief of staff at the Memphis hospital, said the doctor involved in caring for two of the patients who died “no longer works at our medical center.”

Other reforms have been implemented, including better equipment and procedures for monitoring patients.

“Memphis VA takes this issue very seriously, and has acted to address and correct issues directly contributing to the deaths,” the statement from Marino says.

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