Records show scope of patient harm at VA facilities

Amid the recent controversy over whether the Veterans Health Administration (VHA) accurately reported the number of patients who died waiting for an appointment, a new report from the Washington Free Beacon sheds some light on just how many patients were harmed while seeking care at VA facilities.   

The Beacon reveals that 1,452 adverse events were reported at all VA facilities since 2010, 526 of which resulted in patient deaths, according to  VA records that the newspaper obtained through a Freedom of Information Act request.

These numbers are in stark contrast to the figures widely disseminated by the VHA during the height of a scandal surrounding the extreme delays in care and secret wait lists kept by administrators to conceal the backlog of appointments. Those figures--claiming 76 patients were harmed and 23 died while waiting for care since 1999 at two of the facilities embroiled in the scandal--were called into question by a recent report from the VA Office of Inspector General, which characterized the VHA report as "misleading" and inaccurate, FierceHealthcare reported.

The records detailing adverse events in fiscal years 2011, 2012 and 2013 for all VA facilities not only reveal common events such as medication errors and hospital-acquired conditions (HACs), but also more disturbingly, dangerous delays in cancer diagnoses. VA facilities in Gainesville, Florida; Augusta, Georgia; and Columbia, South Carolina, reported some of the highest numbers of cancer screening delays, which impacted the facilities' ability to provide treatment and ultimately, the patients' rate of survival, according to the Beacon analysis.

Another troubling pattern in the VA's records of adverse events included lapses in screening and treating patients who were found to be at risk for suicide. Though the VA has made it a priority to improve its mental health treatment, the most recent data indicate that suicide is on the rise among young veterans, with the department estimating that about 22 veterans take their own lives each day.

The VA records provided to the Beacon are riddled with accounts of VA staff failing to address mental health concerns from patients or the patients' friends and family. In one case, a "lack of appropriate follow-up and medication regime" resulted in a patient attempting suicide by stabbing him or herself in the neck with a knife; in other cases, the records attribute drug overdoses or other successful or non-successful suicide attempts to staff failing to perform risk assessments.

To learn more:
- read the article
- check out the VA data summary

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