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Report: VA hospital put patients at ‘unnecessary risk’ due to poor inventory management

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An investigation by the Department of Veterans Affairs Office of Inspector General found that a District of Columbia VA hospital engaged in practices that put patients at “unnecessary risk.”

The OIG conducted its investigation of Washington DC VA Medical Center at the end of March and returned for a second visit during the first week of April, according to its report (PDF). It found that 18 out of the hospital’s 25 sterile storage areas were dirty and staff had failed to inventory or account for $150 million in equipment, which led to delays for patient procedures.

The investigation did not find any incidents of patient harm connected to these issues. But delays were significant, according to the report; for instance, four prostate biopsy surgeries were cancelled because biopsy guns were not available for the procedures.

In response to the findings, on Wednesday the VA removed the hospital's medical director, Brian A. Hawkins, from the position and appointed department policy adviser Col. Lawrence Connell as acting medical director, the department announced. Earlier in the day the VA tapped Charles Faselis, M.D., the hospital’s chief of staff, to fill the role, but changed course.

“VA is conducting a swift and comprehensive review into these findings,” the department said in the statement. “VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law.”

The findings are not complete, according to the OIG, but Inspector General Michael Missal said a “lack of confidence” that the Veterans Health Administration would address the problems compelled them to release recommendations before the investigation is fully completed.

The OIG’s recommendations include that the VA implement a new inventory management system at the D.C. hospital to ensure that supplies are available for care and that inventory be managed in an off-site warehouse. It also called on the organization to immediately fill vacant clinical leadership roles, like associate medical director, nurse executive and chief of logistics.

The VA’s health system has been under a microscope since 2014, when news broke that patients in the system faced unacceptably long wait times for care. Investigations found that the VA’s method for recording wait times often underestimates how long patients wait for care  In response, this week the VA launched a new site that allows patients to look up average wait times for appointments at VA hospitals in their area.

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