Department of Veterans Affairs Office of Inspector General (214.4 KB)
Office of Inspector General Report on Quality of Care Issues at the Louis A. Johnson VA Medical Center, Report No. 09-02950-58
January 29th, 2010Service members have little recourse against malpractice
January 29th, 2010Just before midnight on Feb. 20, 2007, she gave birth by cesarean section to a healthy boy.
But Wilson never got to hold her baby. According to her medical records, a uterine artery was cut during the delivery, causing massive internal bleeding. The estimated blood loss was equivalent to the total blood volume of an average adult.
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Willing to die, but not this way
January 29th, 2010Minutes after routine surgery for acute appendicitis in October 2003, Staff Sgt. Dean Witt, 25, was being moved to a recovery room at a Northern California military hospital when he gasped and stopped breathing.
A student nurse assisting an understaffed anesthesia team tried to resuscitate Witt and failed. Inexplicably, Witt’s gurney was wheeled into a pediatric area. Lifesaving devices sized for children, not a 175-pound adult, proved useless, according to an internal report on the incident.
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Webb visits VA medical center after receiving complaints
January 29th, 2010U.S. Sen. Jim Webb made his first visit Friday to the Hampton VA Medical Center, where he praised the dedication of health care workers but said he is still following the incomplete investigations of many patient complaints.
In the fall, Webb asked the U.S. Department of Veterans Affairs to examine the quality of care at the Hampton facility after his office had received 149 complaints, including allegations that ranged from abusive patient treatment to wrongful death.
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VA clinic now concedes violations
January 29th, 2010In a dramatic about-face, the Philadelphia VA Medical Center has acknowledged that its troubled prostate cancer program violated federal radiation rules meant to protect patients from harm.
Just last month, Philadelphia VA officials disputed the finding of a Nuclear Regulatory Commission investigation that the hospital committed eight safety violations in its prostate brachytherapy program.
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GAO Calls for Stronger Credentialing, Privileging Oversight at Facilities
January 12th, 2010The Government Accountability Office (GAO), after reviewing credentialing, privileging, and performance monitoring procedures at several Department of Veterans Affairs (VA) medical centers, has called for several areas of improvement among those facilities.
GAO’s interest began when seven out of 180 patients diedâa rate that was far greater than expectedâbetween October 2006 and March 2007 at a VA medical center in Marion, IL. This prompted an investigation by the VA Office of Inspector General (OIG), which later issued a report that identified numerous deficiencies related to credentialing, privileging, and monitoring surgical care.
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Did communications breakdowns imperil Utah VA patients?
January 4th, 2010Communication breakdowns between two medical departments may have compromised the care of patients being treated in the Veterans Affairs Salt Lake City Health Care System, according to a new report by the VA Office of Inspector General.
But the report, released Monday afternoon, did not substantiate an unidentified complainant’s allegations linking the failures to four patients’ deaths at the VA Medical Center.
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NRC cites VA clinic for radioactive-treatment violations
December 16th, 2009In the first outside report on its flawed prostate-cancer program, the Philadelphia VA Medical Center was cited for eight apparent violations in using radioactive materials on nearly 100 veterans, federal inspectors have concluded.
The Nuclear Regulatory Commission found that the Philadelphia VA staff failed to evaluate radiation doses or know when to report a mistake, according to the 16-page report obtained yesterday by The Inquirer.
The brachytherapy team, for example, failed to check radiation doses for more than a year because a computer was unplugged from the hospital’s network, the report said.
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Calls for “Tort Reform” Desperate Distraction From Health Care Debate
December 14th, 2009Those opposed to real health care reform are flailing to come up with real, alternative solutions to our current crisis. With all the talk of death panels, government takeovers, and rationing of care, now tort reform has been thrown into the mix.
Yet it will do practically nothing to lower health care costs, and certainly will not fix our broken health care system. However, it will most definitely hurt patients injured through no fault of their own. Seemingly, the effects of legislation on real people have somehow evaporated from the discussion.
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Report: Problems Still Plague Illinois VA Hospital
December 14th, 2009A new report from the inspector general in the Department of Veterans Affairs finds that the VA Medical Center in Marion, Ill., continues to be plagued by quality management and patient care problems some two years after a suspicious spike in the number of post-surgical patient deaths there.
A 2008 investigation found that at least nine patients died because of surgical mistakes and poor post-surgical care at the VA hospital in Marion, which is in southern Illinois. That report made recommendations to improve conditions at the facility.
The new report finds poor quality management oversight, inconsistencies in the way patient deaths are reported and continuing problems with ensuring patient safety â including the discovery that surgeons were performing procedures they were not authorized to handle.
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