A doctor drunk on the job misdiagnosing patients and a nursing assistant who intentionally killed patients with insulin – those are some examples of tragic failures at Veterans Health Administration (VHA) facilities in recent years, which lawmakers focused on in a hearing on Capitol Hill Wednesday.
A House panel heard from the Office of Inspector General for the Department of Veterans Affairs (VA) and the U.S. Government Accountability Office (GAO) about how these cases could have and should have been prevented.
“Some leaders across multiple levels of VHA do not consistently ensure the safety of the veterans they serve,” said Dr. Julie Kroviak, Deputy Assistant Inspector General for Healthcare Inspections for the Office of Inspector General for the VA.
The testimony centered on several tragic examples.
In January, a former pathologist who worked at an Arkansas VA medical facility was sentenced to 20 years in prison after investigators say he routinely was drunk on the job and misdiagnosed thousands of veterans.
In May, a former nursing assistant who worked at a West Virginia VA medical facility was sentenced to seven life sentences after she admitted to intentionally giving deadly insulin injections to elderly patients.
Over the summer, lawmakers said a veteran took his own life just hours after he was discharged from a Las Vegas VA medical center.
“He left the facility without an updated suicide safety plan,” said Rep. Julia Brownley (D-Calif).
“Something must change,” said Rep. Jack Bergman (R-Mich.).
“In each of these examples, the unfortunate outcomes could have been minimized or prevented had leaders created and supported an environment that prioritized patient safety,” said Kroviak.
Government watchdogs said the failures in large part stem from weaknesses with accountability.
“Weaknesses in its oversight that could result in harm to health or safety or that the risk could result in injury or loss of life,” said Sharon Silas, Director of the Health Care Team for GAO.
The VHA said it has been working to improve information sharing and oversight at the regional and national levels.
“Know that we are also concerned about our accountability,” said Renee Oshinski, Assistant Under Secretary for Health for Operations at VHA. “We value transparency and are working to change our culture across the system to make sure we report events and prevent future harm.”
Oshinski said VHA has made several changes at the headquarters level to improve operations.
Her written testimony said that included “evaluating the storage and security of high-alert medications and reviewing the use of a rescue medication flagging system to evaluate unexplained adverse patient events and ensuring its systems promote local willingness to raise and to investigate unusual or unexpected deaths by supporting more effective local review and higher-level oversight.”
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