Conditions are so dangerous at the Department of Veterans Affairs Medical Center in Washington, D.C., that the agency's chief watchdog issued a rare preliminary report Wednesday to alert patients and other members of the public.
The VA inspector general found that in recent weeks the operating room at the hospital ran out of vascular patches to seal blood vessels and ultrasound probes used to map blood flow.
The facility had to borrow bone material for knee replacement surgeries. And at one point, the hospital ran out of tubes needed for kidney dialysis, so staff had to go to a private-sector hospital and ask for some.
The hospital, which serves more than 98,000 veterans in the nation’s capital, lacks an effective inventory system, the inspector general determined, and senior VA leaders have known about the problem for months and haven’t fixed it. Investigators also inspected 25 sterile storage areas and found 18 were dirty.
“Although our work is continuing, we believed it appropriate to publish this Interim Summary Report given the exigent nature of the issues we have preliminarily identified and the lack of confidence in VHA adequately and timely fixing the root causes of these issues,” VA Inspector General Michael Missal wrote.
The inspector general rarely issues such preliminary findings. The last time appears to have been in January 2015, when his office found lapses in urology care at the Phoenix VA were endangering patients and required “immediate attention.”
The VA set up an incident command center on March 30 when the inspector general notified officials about the problems in Washington; it sent logistics specialists, technicians and managers to fix the problems.
Such actions, Missal said, are "short term and potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues identified.
“Further, shortages of medical equipment and supplies continued to occur…, confirming that problems persisted despite these measures,” he wrote.
His investigation, which stemmed from an anonymous complaint on March 21, found that during the past three years, there have been 194 reports that patient safety has been compromised because of insufficient equipment.
Among the findings:
• In February 2016, a tray used in repairing jaw fractures was removed from the hospital because of an outstanding invoice to a vendor.
• In April 2016, four prostate biopsies had to be canceled because there were no tools to extract the tissue sample.
• In June 2016, the hospital found one of its surgeons had used expired equipment during a procedure
• In March 2017, the facility found chemical strips used to verify equipment sterilization had expired a month earlier, so tests performed on nearly 400 items were not reliable
Missal said that the practices have placed patients at “unnecessary risk,” though so far, the Office of Inspector General has not determined if patients were harmed.
“The OIG’s work is continuing and will include an assessment of whether patient harm has resulted from any of these inventory practices in its final report on the Medical Center,” he wrote.
A spokesman for the VA did not immediately respond to a message seeking comment.
New VA Secretary David Shulkin told USA TODAY earlier this week that he welcomes outside oversight with hopes it will help him fix the beleaguered agency.
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