Probe Of Veterans Affairs Hospital Shows Patients Were Put At Risk

Steve Inskeep talks to VA Inspector General Michael Missal about an investigation into the D.C. Veterans Affairs Medical Center. It found serious issues regarding the handling of medical equipment.

STEVE INSKEEP, HOST:

And let's turn now to a military story closer to home. Investigation of a veterans hospital found chaos. The secretary of Veterans Affairs replaced the head of the medical center in Washington which serves 100,000 patients. He acted after a report by VA Inspector General Michael Missal who's on the line to talk about this.

Inspector general, welcome to the program.

MICHAEL MISSAL: Thanks for having me, Steve.

INSKEEP: How bad is it at this one hospital?

MISSAL: We found a number of serious and troubling deficiencies at the medical center. One of the more significant things we found is there were no effective inventory system for managing the availability of medical equipment and supplies used for patient care; no effective system to ensure supplies and equipment which were subject to patient recalls were not used on patients. Over $150 million in equipment or supplies that had not been inventoried in the past year, therefore, had not been accounted for.

We also found a large offsite warehouse full of non-inventory equipment and materials with a lease expiring at the end of this month and with no plan to move the materials. Also, 18 of 25 sterile satellite storage areas that we reviewed we found were dirty. And finally, there were numerous and critical open staff positions that will make proper remediation of these matters very difficult.

INSKEEP: Inspector general, I want to try to underline what the stakes were here because when you say a phrase like no effective inventory system, some people's eyes might glaze over a little bit. It might be hard to grasp why that's even all that important. But I suppose we're talking about a situation where you may need medical supplies urgently and not know how to find them. Were peoples' lives actually at stake here?

MISSAL: We found that there was a serious risk to patients. Let me give you a couple of examples to really drive this home. In March, the medical center ran out of blood lines for dialysis patients. So therefore, they had to go to another medical center to get the blood line so that dialysis services could be given.

We also found while we were on site that the tubes used to give oxygen to patients in need were out of certain supply rooms, and people had to scurry around the hospital to get it. And then there was also problems in the operating room, where procedures had to be either postponed or canceled because they didn't have the proper equipment to do the operation as safely as it should have been done.

INSKEEP: Do you suspect that people died as a result of this?

MISSAL: I don't have any evidence of that at this time. Our work is continuing, and we're going to look very carefully to see if there was any adverse patient outcomes.

INSKEEP: You know, Inspector General Missal, every now and again of course there's been a scandal at a VA medical facility, and now we have this one at the medical center in Washington, D.C. And when we hear about them, at least from the outside, it often sounds like mainly a question of management. In this case, you're talking about an ability to get storerooms cleaned properly, an ability to have a proper inventory system. Does the VA tend to attract good managers?

MISSAL: I think they have a number of dedicated employees who are trying to do the best job they can for veterans. One thing we're going to be looking at very closely in this report because our work is continuing - we've only been on the site about two weeks - is to determine why this happened and also the root cause of the issue so that if there is management challenges and problems, we're going to identify them very clearly.

INSKEEP: Your report doesn't even just talk about a lack of good management - a lack of management. You write there are numerous and critical open senior staff positions. Is it hard to find anybody at all to do these jobs?

MISSAL: It's always challenging to hire people. But as I said, given the mission - so important to help veterans who so richly deserve the services and benefits that the VA has to offer, there are many people who would love to work there. The issue, though, is making sure you have the right people in the right jobs and the right system to manage those people.

INSKEEP: Is the situation stable now?

MISSAL: We don't know if it's stable. We know that the secretary has made changes, and they're working hard to do so. We made eight recommendations to get this facility back to the stage we think is appropriate. And we hope they implement them promptly - properly.

INSKEEP: Inspector General Missal, thanks very much.

MISSAL: Thank you so much.

INSKEEP: Michael Missal is the inspector general of the Department of Veterans Affairs, which has just looked into conditions at the Washington, D.C., medical center.

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