Equipment and supply problems at the Washington, D.C. VA Medical Center could place patients at serious risk, and resulted in the firing of the center’s director.
The Office of Inspector General (OIG) in the U.S. Department of Veterans Affairs issued an interim summary report (PDF) on April 12, detailing serious deficiencies and problems at the D.C. Medical Center. The report came following inspections in March, following complaints about equipment and supply issues.
The inspections took place from March 29 to March 30, and April 4 to April 6. Investigators returned again for an onsite inspection on Wednesday, according to the report.
“OIG has preliminarily identified a number of serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk,” the report states. “At least some of these issues have been known to the Veterans Health Administration (VHA) senior management for some time without effective remediation.”
Investigators discovered not only was there no effective inventory system for medical equipment and supplies used for patient care, but it found that no system was in place to ensure that recalled medical devices were not in use on patients, 18 of the 25 sterile satellite storage areas were dirty, and more than $150 million in equipment and supplies is unaccounted for, among other problems.
The OIG noted that these practices put patients at serious risk, because it means that the VA could not ensure that the proper medical supplies and equipment were available or sterile when needed. There was also no way to be certain that the staff did not use medical devices on patients that may have been recalled.
While the OIG has not linked any patient injuries or deaths to the problems, they have raised serious concerns.
“At the time of our site visit, the Medical Center was in the process of conducting a patient safety review because sterile processing ran out of supplies to test the insulation of scopes used in laparoscopic or endoscopic procedures. This testing is used to detect holes in the insulation surrounding the scopes that may result in the transmission of electrical current into surrounding tissues,” the report states. ” If this occurs, patients may develop burns or latent infections. The Medical Center could not verify whether this testing had been done on scopes used in approximately 20 procedures since February 28, 2017-March 16, 2017.”
Since March alone, the Medical Center ran out of things such as oxygen nasal cannulas, bone cement, dialysis bloodlines and needles, vascular patches, Doppler probes, alcohol pads, denture cups, etc. In many cases the issue was restricted to one floor’s supply room, but in some cases they affected the entire hospital.
OIG investigators found cases over the past several years where surgeries could not be performed, or in some cases, surgeries were performed without all of the equipment the operating room staff wanted on-hand. The report found 194 patient safety reports that were linked to supply and equipment problems since January 1, 2014.
“Four prostate biopsy surgical procedures were canceled on April 25, 2016 because prostate biopsy guns were out of stock,” the report notes in one example. “A nurse wrote an email to the medical center director on April 26, 2016 recommending an OR ‘stand down’ until the operating room’s inventory situation could be remedied.”
Shortly after the report was released, VA officials announced that they had relieved the medical center’s director, demoted him, and relegated him to administrative duty. On Thursday, the VA announced that retired Army Colonel Lawrence Connell would serve as the acting medical director while the investigation continued.