No patient died as a result of the patient safety issues at the Washington facility dating back to at least 2013, which resulted in costly hospitalizations, "prolonged or unnecessary anesthesia" while medical staff scrambled to find needed equipment at the last minute, as well as delays and cancellations of medical procedures. The report also noted improvements made at the Washington facility since the IG's first report in April, when Shulkin replaced the medical center's director and pledged broader improvements.