Whistleblowers blast VA hospital for 'troubling' patient care failures

Patients at risk from various unsafe practices, Office of Special Counsel tells White House
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The Office of Special Counsel (OSC), citing a series of whistleblower complaints at a Veterans Affairs medical center in Jackson, Miss., warned the White House and Congress of "serious questions" about the hospital's ability to care for veterans.

In a March 18 announcement, OSC outlined five troubling whistleblower investigations alleging problems with quality of care at the G.V. "Sonny" Montgomery VA hospital--including two cases in which OSC says the VA dropped the ball during its own investigations.

Three of the five investigations involved unsafe sterilization techniques, with the VA confirming in 2009 that "dirty, rust-stained instruments" were sent to the hospital's operating rooms and clinics. The VA outlined steps to correct longstanding problems in the sterilization department.

But after the VA failed to substantiate a 2011 whistleblower complaint that unsafe sterilization practices continued, OSC "determined that the VA's findings were unreasonable, in part because they were made without interviewing the whistleblower, who disputed much of the VA's response," according to the announcement.

That same year a whistleblower said the medical center's spokespeople were told to purposely mischaracterize the original 2009 findings, OSC said. The VA found false statements were made to the public and Congress, but concluded the statements were not intentionally inaccurate because hospital management were informed of the violations. OSC disagreed.

Two other complaints are still being investigated.

Last year a physician alleged that nurse practitioners were prescribing narcotics without proper training or authorization--or in some cases without seeing the patients--because of chronic understaffing in the primary care unit. The physician also alleged the hospital fraudulently completed several Medicare Home Health Certifications because of inadequate physician staffing. The case was referred to the VA for investigation in February.

In the final case, with an investigation pending, a whistleblower alleged hospital management failed to notify patients possibly affected by a radiologist's failure to properly read thousands of images. The hospital already knew of cases where the radiologist failed to diagnose fatal illnesses, OSC said.

OSC's letter to the president and Congress was "unusually strong" and warned of a "troubling pattern of disclosure" at the hospital, The New York Times reported. The VA in Washington issued a statement saying it would continue working to improve processes and services, accoridng to the article.

In another VA case involving patient safety issues, more than 700 patients at the Buffalo (N.Y.) Veterans Administration Medical Center may have been exposed to HIV, hepatitis B or hepatitis C through the unintentional reuse of insulin pens, a routine pharmacy inspection last November found.

In 2011 the John Cochran Veterans Administration Hospital in St. Louis suspended surgeries after finding dirty tools and unsanitary conditions. The previous year the same hospital put more than 1,800 veterans at risk for HIV because of improperly washed dental equipment.

To learn more:
- here's the OSC announcement (.pdf)
- read the New York Times report

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