VAmalpractice.info-Information about medical malpractice by VA doctors, & VA nurses & how the VA handles medical malpractice tort claims, section 151 benefits, lawyers who represent veterans with malpractice claims and other things that adversely affect the quality of medical care that veterans receive from the Department of Veterans Affairs.
Information on medical malpractice by VA, or Veterans Administration hospitals, physicians, and clinics run by the Department of Veterans Affairs. While many veterans receive satisfactory medical care from the VA, others do not. This site is designed to provide information to those veterans, who have received negligent medical care, from a Veterans Administration hospital, doctor, physician’s assistant, surgeon or other VA medical provider and to encourage discussion about this problem. The VA is responsible for the US paying out millions of dollars a week for medical malpractice claims under the Federal Tort Claims Act. It would be better for our veterans, and for the taxpayers, if the VA chose to provide better medical care instead.
Sign our White House petition to require the VA to stop using former Soviet Officers to treat our veterans!
The VA should be required to fire all former Soviet Officers, who are physicians!
As shocking as this sounds, the VA currently employs physicians who are former Soviet officers to treat veterans.
It is inappropriate for veterans to be treated by former Soviet officers, particularly, if the physician does not disclose his prior status, it is particularly offensive, when Cold War era veterans recieve psychiatric treatment from a former Soviet officer who may lack the basic understanding of our culture necessary to treat our veterans’ mental illnesses.
The VA should be required to fire these former soviet officers, or at a minimum require them to disclose their former Soviet military status so that veterans may chose whether they want to receive treatment from another medical provider.
As I have received some comments that my claim that the VA employs former Soviet Officers is baseless, and is completely without merit, and that I am crazy for saying such things here are some quotes form the deposition of the VA doctor in question, Iv’e omitted the name of the medical school that he attended because that would make it too easy to figure out which VA hospital I’m referring to:
………You went to medical school in –
A. I went to medical school in Russia. And where did you go?
A. The name is ———————————
Q. And could you tell me, when did you graduate from —————–
A. June, 1991.
Q. And how long is medical school or was medical school in Russia at that time?
A. Six years.
Q. And after you graduated from medical school in Russia, what did you do?
A. I did my — I did my residency in OB-GYN and after that I practiced as an OB-GYN.
Q. You practiced as an OB-GYN physician for how long?
A. 1990 till 1992.
Q. When you went to medical school in Russia, was it necessary for you to have any level of military service or governmental service obligation as a result of that education?
A. As a part of our education we went to we studied military medicine and also while in medical school we went to a special summer camp for two months and when I graduated I received I was lieutenant medical something. I had the rank of lieutenant.
Q. And was that in the Soviet Army, Navy?
A. Lieutenant of the Reserve…….
If we reach our goal of 100,000 signatures, I will release the name of one physician who is currently employed by the VA who was an officer in the Soviet Army, who is currently treating veterans. Remember you saw it first here.
W. Robb Graham
Sign our White House petition to require the VA to stop using former Soviet Officers to treat our veterans!
Veterans dying because of health care delays
CNN) — U.S. veterans are dying because of delays in diagnosis and treatment at VA hospitals.
At least 19 veterans have died because of delays in simple medical screenings like colonoscopies or endoscopies, at various VA hospitals or clinics, CNN has learned.
That’s according to an internal document from the U.S. Department of Veterans Affairs, obtained exclusively by CNN, that deals with patients diagnosed with cancer in 2010 and 2011.
Hospital delays are killing war vets
The veterans were part of 82 vets who have died or are dying or have suffered serious injuries as a result of delayed diagnosis or treatment for colonoscopies or endoscopies.
Barry Coates is one of the veterans who has suffered from a delay in care. Coates was having excruciating pain and rectal bleeding in 2011. For a year the Army veteran went to several VA clinics and hospitals in South Carolina, trying to get help. But the VA’s diagnosis was hemorrhoids, and aside from simple pain medication he was told he might need a colonoscopy.
Congress demands answers on VA deaths
“The problem was getting worse and I was having more pain,” Coates said, talking about one specific VA doctor who he saw every few months. “She again examined me and gave me some prescriptions for other things as far as pain and stuff like that and I noticed again she made another comment — ‘may need colonoscopy.’
“I told her that something needed to be done,” said Coates. “But nothing was ever set up … a consult was never set up.”
“I had already been in pain and suffering from this problem for over six months and it wasn’t getting better,” Coates said. “I told her that if you were in as much pain as I was and had been going through you wouldn’t wait another two months to see what’s going on. You would probably do it this week.”
Coates waited months, even begging for an appointment to have his colonoscopy. But he only found himself on a growing list of veterans also waiting for appointments and procedures. He was finally told he could have a colonoscopy, many months later.
“I took it upon my own self to call the department that scheduled that and ask them about it. And they said this was the earliest appointment that I could get. And I explained to the lady what I had already been through and how much pain I had, and I said if I wait this long there might not be … (anything) we can do about it then. I could be even dead by then. And the only thing she could tell me was ‘I understand that, sir, but I don’t have any control over that.’ ”
Finally about a year after first complaining to his doctors of the pain, Coates got a colonoscopy and doctors discovered a cancerous tumor the size of a baseball.
The now 44-year-old veteran is undergoing chemotherapy in an effort to save his life.
It is unclear whether anyone responsible at the VA has been fired, demoted or even admonished for the delays in care and treatment. Some of the people responsible may have even received bonuses in recent years for their work, despite the delays in care or treatment for the veterans.
According to the document obtained by CNN, 10 veterans are confirmed to have died in the South Carolina and Georgia region alone. And the document shows 29 vets or their families were sent the disclosures, notifying them they had serious “adverse events” because of delayed care. And according to the document the problems go far beyond Georgia or South Carolina.
In the Florida region, five veterans are dead, and 14 vets or their families were sent the disclosures, notified that they suffered “adverse events” because of delayed or denied care or diagnosis, according to the exclusive document.
In the Rocky Mountain region, two veterans died, and four families were sent the disclosures or notified. In the Texas region, seven vets or their families were sent disclosures about adverse events and serious injuries suffered because of delayed care.
Coates filed a legal claim, citing the “failure of the Columbia (South Carolina) VA Medical Center to timely diagnose his rectal cancer.” The VA settled, but admitted no wrong-doing.
“I don’t know what my outcome is going to be,” said Coates.
“I just try to live every day like it’s my last day.”
The new document obtained by CNN shows a worse problem than has previously been made public by the VA.
As CNN has previously reported, as many as 7,000 veterans were on a backlog list — waiting too long for colonscopies or endoscopies — at VA facilities in Columbia, South Carolina and Augusta, Georgia.
After CNN’s detailed accounting of dela-related deaths at the Columbia and Augusta VA hospitals, a bi-partisan group of Congressmen visited the hospitals, demanding answers.
“We have a duty to make sure that the veterans who serve get the best health care possible,” said Rep. John Barrow, D-Georgia. “And it is very obvious that for too long and for too many folks that hasn’t happened.”
The VA said the backlog at those two hospitals has been solved, but that is not a good enough explanation for Rep. Jeff Miller, the chair of the House Veterans Affairs Committee.
“The fact that we’ve had veterans who have died in the very facilities that are supposed to be taking care of them, and not by natural means, by means that could have been prevented is egregious,” said Miller, R-Florida. “And it’s not acceptable.”
Miller said the VA, from the top down, has consistently ignored his committee’s requests to find out who is responsible. Even with the delays in care which have led to deaths and serious injuries, the congressman said not a single person has been fired or even demoted, and in fact some of those responsible may have even gotten bonuses.
“I grieve for the families who lost loved ones that could have been with them this Christmas that would be celebrating 2014 today had the backlog not existed,” said Miller. “That’s not what anybody in this country wants for our veterans.”
He said the lack of accountability is what angers him most.
“That’s why we asked the question again today, with members of the South Carolina delegation and Georgia delegation, tell us exactly who was disciplined and how. I don’t want to hear the excuse anymore that ‘It was multi-faceted. …There were many people involved’ ” said Miller.
“Well if there were many people involved then they all need to go. We are not asking for one particular person, we want to know exactly why things happened and who was held responsible, At this point publicly, we haven’t seen anybody held responsible.”
CNN has made repeated requests for interviews with top officials at the VA, including President Obama’s appointed head of the Department of Veterans Affairs, Secretary Eric Shinseki. The requests have all been denied, or ignored.
The VA did issue a written statement from Dr. Robert Petzel, the Under Secretary for Health at the department of Veterans Affairs. In the statement, Petzel wrote that “The Department of Veterans Affairs (VA) cares deeply for every Veteran we are privileged to serve. Our goal is to provide the best quality, safe and effective health care our Veterans have earned and deserve. We take seriously any issue that occurs at any one of the more than 1,700 VA health care facilities across the country.”
He also stated: “As a result of the consult delay issue VA discovered at two of our medical centers, the Veterans Health Administration (VHA) conducted a national review of consults across the system. We have redesigned the consult process to better monitor consult timeliness. We continue to take action to strengthen oversight mechanisms and prevent a similar delay at another VA medical center. We take any issue of this nature extremely seriously and offer our sincerest condolences to families and individuals who have been affected and lost a loved one.”
In August 2007, presidential candidate Barack Obama gave a campaign speech to veterans specifically addressing wait lists, denied care and poor treatment of vets. He promised his administration would be different.
“No veteran should have to fill out a 23-page claim to get care, or wait months — even years — to get an appointment at the VA,” said then-candidate Obama.
“When we fail to keep faith with our veterans, the bond between our nation and our nation’s heroes becomes frayed. When a veteran is denied care, we are all dishonored.”
But Coates said for him the speech is an empty promise.
“Someone needs to stand and face the person who suffered and the veterans who have died and say, ‘Hey it was me, I let the ball drop,’ ” he said.
“How many lives are we going to lose from this?”
“When is it going to be corrected?”
VA agrees to $12,000,000 settlement for medical malpractice during brain surgery on veteran at a VA hospital.
December 2, 2013 (WLS) – A Chicago-area Vietnam veteran will get a $12 million medical malpractice settlement from the federal government.
John Johnson suffered severe brain damage during surgery at the Hines VA Hospital five years ago.
His lawyers say doctors did not adequately prepare for and monitor his heart condition when he was put under anesthesia.
His lawyers say the money will be used to help cover his medical and day-to-day living expenses.
Trouble in Tennessee!
VA OIG confirms that malpractice at the Memphis VA emergency room contributed to the deaths of 3 veterans!
The VA OIG has released an investigation that confirms medical malpractice was responsible for the deaths of 3 veterans at the Memphis Tennessee VA. The substandard medical care that led to the deaths of these veterans all took place in the emergency department. In the first case, the veteran was administered a drug that he had a documented allergy to. He died 8 days later. In the 2nd case, a veteran was found not breathing and unresponsive in the emergency department; a subsequent review revealed that his monitoring equipment had stopped functioning forty minutes before he was found unresponsive. This veteran died 13 days later. A 3rd veteran was admitted to the emergency room with signs and symptoms that should’ve resulted in more aggressive management. Due to a combination of mistakes in the emergency department there was a tremendous delay in diagnosing the fact that there was bleeding occurring in the patient’s brain. He died the next day.
These are the OIG’s descriptions of the cases:
Patient 1. The patient arrived at the facility ED complaining of back and neck pain. The ED triage1 nurse documented in the EHR that the patient’s condition was non-urgent, listed the patient’s allergies, including aspirin, and indicated that the allergies were verified with the patient. A physician’s progress note entered approximately 3½ hours later made no mention of allergies. The physician ordered ketorolac (a non-steroidal anti-inflammatory pain medication) to be administered intramuscularly for the patient’s back pain. This medication is contraindicated for patients with an allergy to aspirin. The physician’s order for ketorolac was hand-written rather than being entered into the EHR as required by local policy. Entering the order electronically would have generated an alert that the medication was contraindicated due to the patient’s drug allergy. A few minutes after the physician wrote the order, a staff member administered the ketorolac, and the patient was discharged from the ED approximately 10 minutes after receiving the medication. An hour later the patient returned to the ED by ambulance in full cardiac and respiratory arrest. A different physician saw the patient and noted the drug allergy. The patient had a breathing tube inserted, was placed on a ventilator, and was transferred to the Medical Intensive Care Unit (MICU). The patient died 8 days later after the family agreed to discontinue life support
Patient 2. The patient arrived at the facility ED complaining of back pain described as “10” on a scale of 0 (no pain) to 10 (unbearable pain). A physician saw the patient and hand-wrote orders for hydromorphone (a narcotic pain medication) 2 mg to be administered intravenously2 (IV), ondansetron (an anti-nausea medication) 4 mg IV, lorazepam (a tranquilizer) 1 mg IV, and dexamethazone (a potent steroid medication with anti-inflammatory properties) 4 mg IV). Both hydromorphone and lorazepam have sedating properties.
The patient was in a “Level 2” ED bed, not in the main ED area. The patient rooms in this area are not visible from the main ED and do not have bedside electrocardiographic, oxygen saturation, or vital signs monitors connected to the central monitoring system in the main ED. The patient was connected to a portable oxygen saturation monitor that should alarm if there is a critical change in oxygen saturation level; however, staff would have to be within hearing range of the monitor since it was not connected to a centralized monitoring system. According to the EHR, the registered nurse (RN) checked on the patient 45 minutes after administering the medications and found him to be unresponsive and not breathing. ED staff began resuscitation efforts, a breathing tube was inserted, and the patient was placed on a ventilator. He was transferred to the MICU, where he remained in a coma until he died 13 days later. A retrospective review by the facility revealed that the oxygen saturation monitor had stopped recording data approximately 40 minutes before the patient was found unresponsive.
Patient 3. The patient had a history of frequent hospitalizations and complex medical issues, including hypertension, diabetes, congestive heart failure, and end stage renal disease requiring dialysis. The patient arrived at the facility ED complaining of shortness of breath and eye pain. He was noted to have an extremely elevated blood pressure and an ED physician entered an order in the EHR for hydromorphone 1 mg IV and hydralazine (a vasodilator3) 20 mg IV. Approximately one hour later, a nurse documented that the patient was confused, but a subsequent note stated that he was alert and oriented. EHR progress notes reflected that the RN notified the physician that the patient’s blood pressure readings remained very high, but there is no notation that the physician was alerted about the patient’s confusion. A second dose of hydralazine was administered about two hours after the first dose, and the physician documented about an hour after the second dose that the patient was “improving slowly.” Shortly afterwards, another physician came on duty and documented that patient was awaiting admission to an inpatient unit. About an hour later, the RN documented that the patient again complained of eye pain. A few minutes after that, the patient was found unresponsive. A CT scan4 detected bleeding in the patient’s brain. A breathing tube was inserted and the patient was placed on a ventilator in the ED, transferred to the MICU approximately 4 hours later, and died the following day.
These are the OIG’s findings:
We substantiated that a patient was administered a medication in spite of a documented drug allergy, and had a fatal reaction. Another patient was found unresponsive after being administered multiple sedating medications. A third patient had a critically high blood pressure that was not managed aggressively, and experienced bleeding in the brain approximately 5 hours after presenting to the ED.
We found that the facility took actions as required by VHA in response to the unexpected patient deaths, but noted that implementation of action plans developed through RCAs was delayed and incomplete.
We found inadequate monitoring capabilities for patients in some ED rooms, an issue identified during our site visit last year.
We also found that nursing ED-specific competency assessments had not been completed.
This is the link to the complete report:
Let’s applaud Chairman Jeff Miller as he takes on the bureaucrats that adversely affect the quality of care that veterans receive.
p executives at the nation’s 152 Department of Veterans Affairs medical centers and regional directors could draw faster penalties for major leadership failures under a House bill expected to be introduced on Tuesday.
Rep. Jeff Miller, R-Fla., chairman of the House Veterans’ Affairs committee, said he plans to introduce the legislation in response to the fatal Legionnaires’ disease outbreak at the VA Pittsburgh Healthcare System and other significant health care failures scattered across the country. If approved, the measure would allow the VA secretary in Washington to fire directly or demote any VA senior executives for subpar job performance, according to a copy of the three-page bill obtained by the Tribune-Review.
“This legislation would give VA leaders a tool to address a problem that continues to get worse by the day. VA’s widespread and systemic lack of accountability is exacerbating all of its most pressing problems, including the department’s stubborn disability benefits backlog and a mounting toll of at least 31 recent preventable veteran deaths at VA medical centers across the country,” Miller said.
“While the vast majority of the VA’s more than 300,000 employees and executives are dedicated and hard-working, the department’s well-documented reluctance to ensure its leaders are held accountable for mistakes is tarnishing the reputation of the organization and may actually be encouraging more veteran suffering instead of preventing it,” he said.
VA spokeswoman Ramona Joyce said the department generally does not comment on pending legislation.
“At least in my observations, the nonprofessional administrative staff is just this self-perpetuating network. It seems to be beholden to no one except itself,” said W. Robb Graham, a Cherry Hill, N.J., attorney who specializes in VA malpractice cases. “If they’re coming up with a way to begin getting rid of some of these directors and senior people, more power to them.”
VA officials in Washington have yet to make clear whether any Pittsburgh VA executives will be disciplined for the Legionnaires’ outbreak.
Pittsburgh VA leaders were repeatedly criticized by lawmakers last year when the Centers for Disease Control and Prevention tied the Legionnaires’ outbreak to Legionella-tainted tap water at VA campuses in Oakland and O’Hara. The water likely sickened at least 21 veterans from February 2011 to November 2012 as the Pittsburgh VA failed to control the common bacteria under standard hospital practices, the CDC found. Five of the patients died.
Pittsburgh VA CEO Terry Gerigk Wolf and her supervisor at the time, regional VA Director Michael Moreland, received performance bonuses of $12,924 and $15,619, respectively, for fiscal year 2011, which included part of the outbreak period.
Pending legislation in Congress would ban such bonuses for senior VA executives for five years and tighten disease-reporting requirements for all VA hospitals, among other new accountability standards. Miller has asked the VA for a review of its performance appraisal system.
Under current regulations, the Congressional Research Service found that senior VA executives who might face discipline are entitled to a variety of special considerations. They include written notice, at least 30 days in advance, that identifies specific reasons for proposed disciplinary action. Executives are permitted “a reasonable time” to respond and can file an appeal, among other options.
In a statement released by Joyce, VA officials in Washington said they have limited the number of senior executives who receive high rankings and “hold those responsible accountable” any time there’s an “adverse incident.”
“Moreland is really on the Move”
He’s taking his $63,000 bonus and running!
In what is hopefully the last edition of “Moreland on the Move,” VISN 4 Director, and tireless self promoter, Micheal Moreland has announced that he is keeping his $63,000 bonus and is “retiring” on November 1, 2013. By retiring and giving VISN 4 the opportunity to recover from the discontent, distrust and discord that has plagued it for the last two years, the man who lists on his resume as his specialty “Finding solutions to unsolvable problems,” may have actually taken the first step in solving the biggest problem that faces VISN 4: Michael Moreland.
During his last month on the job, we are going to be updating this post with some of the highlights of Mr. Moreland’s career. If there are any Congressional investigations, OIG reports or AFGE posts that we’ve missed, please send us the information and we will add them. We want to recognize the man who inspired our own “got bonus?” campaign.
Christopher Ellison went to a veterans medical center in Philadelphia to get eight teeth extracted in 2007. What should have been a routine dentist visit left him permanently incapacitated.
The $17.5 million Ellison and his family received in a malpractice judgment against the Department of Veterans Affairs was the largest against the agency in a dozen years — and one of more than 400 payments the U.S. government made last year to resolve VA malpractice claims, according to agency records obtained through a Freedom of Information Act request. The total cost came to $91.7 million, also the highest sum in at least 12 years.
The cases against the VA have included missed diagnoses, delayed treatment and procedures performed on wrong body parts. U.S. lawmakers and veterans’ advocates say they reflect deep flaws in the agency’s health-care system even as the department tends to more former troops, including those who fought in Iraq and Afghanistan.
“The rapid rise in malpractice judgments against VA mirrors the emerging pattern of preventable veteran deaths and other patient safety issues at VA hospitals,” Representative Jeff Miller, a Florida Republican and chairman of the House veterans committee, said in an e-mailed statement. “What’s missing from the equation is not money or manpower — it’s accountability.”
Miller’s committee held a hearing in Pittsburgh today to probe lapses that include a Legionnaires’ disease outbreak at a VA hospital that killed at least five veterans and also led to malpractice claims. The VA’s inspector general is conducting a criminal investigation into the outbreak, which involved bacteria in the hospital system’s water, Robert Petzel, the department’s undersecretary for health, said during the hearing.
Family members of veterans who died after being exposed to the bacteria said the VA didn’t immediately let relatives know there was a potential health problem.
“For sixteen days my father was allowed to shower and drink the water without any warning,” said Robert Nicklas, whose father, William, a Navy veteran, died last year after the Pittsburgh VA outbreak. “Why were we not warned?”
More veterans are taking advantage of VA medical care, including those requiring more complex treatment. As many as 1.2 million additional soldiers are due to become veterans in the next four years. Some of the soldiers from the wars in Iraq and Afghanistan are suffering post-traumatic stress disorder while others are living with injuries that would have been fatal in World War II or the Vietnam War.
The age of recent veterans may be a contributing factor in the rise of claims payments, said W. Robb Graham, an attorney in Cherry Hill, New Jersey, who has represented former troops filing claims against the agency. Younger claimants tend to get larger malpractice payouts, often tied to how long victims will suffer, he said.
The median age range of veterans who served after the Sept. 11, 2001, terror attacks in New York and Washington was 25 to 34 years old, according to a 2011 Labor Department study. That’s compared to veterans who served during the World War II, Korean War and Vietnam eras, whose median age range was 65 and older, the study said.
“If the VA cuts off the wrong leg of a veteran who is 70 years old and his life expectancy is 75, he’s entitled to five years of damages,” Graham said in a phone interview. “If they cut off the wrong leg of a veteran who is 25, you’re now dealing with someone who is entitled to 50 years of damages.”
The department has 152 hospitals and about 19,000 doctors. Last year, the VA tended to 5.6 million veterans, a 32 percent increase from fiscal 2002, according to agency data.
“It’s the largest health-care system in the U.S., and they do an incredible amount of good work,” said Jerry Manar, deputy director of national veterans service at the Kansas City, Missouri-based Veterans of Foreign Wars. “However, there are so many more things they could do in terms of oversight that they don’t appear to be doing now. As a consequence, sometimes you wind up with poor results that were avoidable.”
The department is “deeply committed to providing the quality care and benefits our nation’s veterans have earned and deserve,” Gina Jackson, a VA spokeswoman, said in an e-mail. “If employee misconduct or failure to meet performance standards is found to have been a factor, VA will take appropriate corrective action immediately.”
The 2012 malpractice payments stemmed from both court judgments and administration settlements. The payouts, made by the U.S. Treasury’s Judgment Fund, rose 28 percent last year from about $72 million in 2011, the VA records showed. Taxpayers have spent at least $700 million to resolve claims filed against the veterans agency since 2001, according to the data.
Many valid VA malpractice claims never get paid, said attorney Graham, who served as a judge advocate general in the Navy in the 1980s. Some are rejected because paperwork isn’t filed properly, he said.
“My strong belief is a lot of lawyers don’t know how to sue the VA,” he said.
Some law firms aren’t interested in representing people suing the federal government because of laws that limit attorney fees to 25 percent of malpractice awards, Graham said.
‘An Alarming Pattern’
In a May letter, Representative Miller asked President Barack Obama to help address “an alarming pattern of serious and significant patient care issues” at VA medical facilities.
The House panel is reviewing the Legionnaires’ outbreak in Pennsylvania, and the department’s handling of two overdose deaths and two suicides at an Atlanta veterans hospital. Also under scrutiny are poor sterilization procedures and possible patient exposure to infectious diseases such as HIV at VA locations.
“We are not here as part of a witch-hunt, to make VA look bad or to score political points,” Miller said during the hearing. “We simply want to ensure that veterans across the country are receiving the care and benefits they have earned.”
The agency isn’t holding employees, especially executives, accountable for preventable deaths, Miller said. Department officials also gave bonuses to doctors even if they practiced without a license or left residents unsupervised during surgery, according to a Government Accountability Office report last month.
The recipients of $150 million in bonuses to VA health-care providers in fiscal 2011 included a radiologist unable to read a mammogram and an emergency-room doctor who refused to see patients, the report found.
Miller has said the VA employees should be punished — not rewarded — for their incompetence.
The number of malpractice claims filed with the VA has remained at 1,544 for the past two years, said Jackson, the agency spokeswoman. The leveling off came after a 33 percent spike in cases to 1,670 between 2010 and 2005, according to an October 2011 GAO report.
The VA’s malpractice payment rates may be similar to national levels, said Anupam B. Jena, an assistant professor at Harvard Medical School and physician at Massachusetts General Hospital.
Less than 25 percent of the claims filed against the veterans agency result in payment, according to the VA. About 20 percent of malpractice claims filed with the largest insurer of physicians between 1991 and 2005 resulted in a payment, according to a 2011 study published in the New England Journal of Medicine, said Jena, who worked on the report.
Last year’s “noticeable increase” in medical malpractice payments was partly due to an “exceptionally large” $17.5 million court judgment, Jackson said in an e-mail. Such payments are “highly variable from year to year,” she said.
That record judgment went to Ellison, who was honorably discharged from the Marines in 2001. He was a 49-year-old electronics technician from Bridgeport, Pennsylvania, in 2007 when he visited the dentist to have eight teeth extracted because of tooth decay and gum disease.
During the procedure at a VA facility in Philadelphia, Ellison’s blood pressure dropped several times to “unusually low” levels, his attorney, Shanin Specter, a partner at Kline & Specter P.C., a law firm in the city, said during a 2011 trial.
Ellison wasn’t sent to the emergency room, and the dentist continued with the extractions, said Specter, son of Arlen Specter, the former senator from Pennsylvania who served as a Republican for more than 28 years and became a Democrat during his last 20 months in office. Arlen Specter died last year.
Ellison had a “catastrophic” stroke while driving his car shortly after leaving the dentist office, Specter said.
The government argued that the veteran’s existing health problems caused the stroke, not the care he received at the VA. Ellison had a history of smoking, diabetes, hypertension and many other stroke risk factors, Thomas Johnson, an assistant U.S. attorney, said during the 2011 trial in U.S. District Court in Philadelphia.
After the stroke, Ellison was left with limited vocabulary, “severe and pervasive deficits in all mental abilities,” and “negative personality changes,” according to court documents.
“He wound up being totally incapacitated, requiring 24-hour-a-day care,” Specter said. “This is about as devastating an injury as a person can have, and that’s what the award reflects.”
To contact the reporter on this story: Kathleen Miller in Washington at Kmiller01@bloomberg.net
To contact the editor responsible for this story: Stephanie Stoughton at firstname.lastname@example.org
VA declares victory over quality of care issues, despite the facts: or
“Maybe they’re drinking too much of their own Kool-Aid”
The September 25, 2013, VA OIG’s report “Quality of Care Issues: Erie VAMC & VA Pittsburgh Health System” is yet another in a series which should be called “More news from Michael Moreland and VISN 4.” The OIG’s 11 page report tells a sorry story about the medical treatment that a veteran received from August 15, 2102 through October 1, 2012 for his liver cancer, it tells an even sorrier tale about the “treatment” that this veteran and his family received from an institution that has the audacity to spend the taxpayer’s money to advertise that “it is better than the best.” These six weeks turned out to be the only medical care that the veteran would ever receive from the VA, as he died on October 6, 2012.
The OIG found:
We substantiated the allegation that VA providers did not diagnose the patient’s cancer..
We found VA providers missed opportunities to identify the patient’s cancer and determined several factors that may have contributed to providers not making the cancer diagnosis…
We substantiated the allegation that the patient’s pain was not fully addressed…
We substantiated the allegation that there were scheduling delays in the patient’s referrals and follow-up care…
We substantiated the allegation that this patient did not receive comprehensive oversight through the continuum of his care…
During interviews, many referring providers from the CBOC, Erie VAMC, and Pittsburgh HSC told us it was difficult to communicate with the gastroenterology and Hepatology Clinic specialists. They told us their phones calls occasionally go unanswered and the specialists did not always return phone messages.
Unfortunately none of these finding are surprising; but what is amazing is the indifference to reality that allows the VISN 4 leadership to continue their tireless campaign of self-promotion and disinformation at the expense of the taxpayers. Let’s look at the dates of this veteran’s treatment and a few other things that were happening in VISN 4:
- 8/15/2012 Veteran’s first contact with VA system
- 9/30/2012 End of VA’s fiscal 2012 year (This is the year that Michael Moreland received the $63,000 presidential award for)
- 9/30/2012 VISN 4 is rated the worst in the country using the VA’s own ASPIRE quality measurement system for Ventilator Acquired Pneumonia
- 10/01/2012 Veteran’s last of 13 contacts with VA system since 8/15
- 10/06/2012 Veteran Dies
- Fall 2012 VISN 4 “Vision for Excellence” features stories proclaiming that healthcare provided to veterans in VISN 4 is better than the health care provided by the top 5 hospitals in the nation.
Despite the tragic care that this veteran received, the fall 2012 “Vision for Excellence” had no trouble extolling the quality of the medical that VISN 4 delivered to veterans and pointed out that its ad campaign “Better than the Best,” informed Veterans that the quality of VISN 4’s care is equal to, or better than, the top five hospitals in the Nation. I’ve seen this ad and it unilaterally declares that VISN 4 “beat” the competition in vague areas like “patient satisfaction” by statistically insignificant percentages. With no explanation if these figures were gathered in the same manner at VA and nonVA institutions, Mr. Moreland enthusiastically claims that VISN 4 took on the likes of Johns Hopkins and won! The odds are pretty good that the veteran in this OIG report, along with a few who died from Legionnaires’ disease probably didn’t return their patient satisfaction surveys, but if they did they might disagree with Mr. Moreland’s evaluation. No matter what you’ve got to give Mr. Moreland credit, not everyone can get up and say that we are better than the best when you’re in the midst of a Legionnaires’ disease outbreak, a congressional investigation and you have the worst record in the entire VA ventilator‐associated pneumonias.
Ironically, nowhere in this “public service announcement” does Mr. Moreland mention that VISN 4 had the worst ventilator acquired pneumonia rate in the entire VA system. Out of the VA’s 23 VISNs, VISN 4’s record was twice as bad as the second worst VISN. This sort of head to head meaningful comparison would have provided veterans with meaningful information and would have been a “public service” because it would have warned veterans that they would have been better off going to any VISN besides VISN 4 if they were concerned about possibly getting ventilator‐associated pneumonia. Instead Michael Moreland just uses a lot of fuzzy math and unilaterally declares victory over all quality of care issues in VISN 4 and led veterans to believe that all is well. This superior level of chicanery did not go unnoticed in Washington, where this sort of thing is considered career enhancing and resulted in appropriated recognition:
…“Better than the Best,” informed Veterans that the quality of VISN 4’s care is equal to, or better than, the top five hospitals in the Nation. This campaign won first prize in VHA’s annual communications awards program in 2012.
- 9/6/2013 Michael E. Moreland endorses the OIG report for the veteran who was treated so poorly at the Erie, VA, prior to his testimony at the 9/9/2013 HVAC hearing to examine preventable deaths and accountability at the VA. That must have put him in the right mood for the hearing. Maybe that’s why he looked so green?
Despite the overwhelming evidence contained numerous VA OIG reports and congressional investigations confirming patient safety lapses in VISN 4, during the last five years, VISN 4 continues to spend money explaining how it has done such a wonderful job dealing with patient safety.The VISN 4 web site continues to boldly state:
When VISN 4 compared its ability to provide quality health care with the best hospitals in the United States, we equaled or exceeded our competition in every category. This is proof that our nation’s heroes are being provided the quality of health care that they richly deserve.
Its most recent issue of “Vision for Excellence” it again extols how much VISN 4 has done in this area. This will be the subject of a future post called “VISN 4’s medical care “quality” publicity blitz, twisting the facts: Delusional fantasy, or indictable fraud?
VISN 4 Director Michael Moreland receives a $62,895 bonus in the wake of patient deaths at a hospital he oversees. Veterans Affairs Pittsburgh Health System receives first lawsuit as a result of Legionella at VAPHS under the Federal Tort Claims Act for the death of a veteran,
Family of VA’s Legionella victim sues government
Attorneys for the widow of a World War II veteran brought a wrongful death complaint on Friday against the federal government, alleging reckless disregard for patients in a Legionnaires’ disease outbreak at the Pittsburgh VA….
…The CDC traced the problem to bacteria-contaminated water at the Oakland and O’Hara campuses of the VA Pittsburgh Healthcare System. At least 21 patients probably or definitely acquired the illness, a severe form of pneumonia, inside the health system, according to CDC findings.
The Nicklas complaint seeks $8 million under charges of wrongful death, infliction of emotional distress and additional violations.
A VA attorney recently suggested negotiations but did not offer specifics, Cohen said.
Pittsburgh VA spokesman David Cowgill said the agency could not comment on pending litigation. A national VA spokesman said he was looking into the matter.
The Nicklases’ sons said in December that the family planned to sue and had initiated a preliminary claim. Federal officials had six months to investigate and respond before the family could formalize a full civil complaint in U.S. District Court. Cohen said the government did not respond to the initial claim.
The Nicklas complaint appears to be the first complete lawsuit filed in connection with the outbreak, although Cohen and other civil attorneys said they hope to file more.
Collectively, they indicated having filed at least four other preliminary claims over fatal and non-fatal cases during the outbreak, with more claims possible. Attorneys said their clients want to protect other veterans from meeting the same fate.
“I still think my brother would have had a lot more life left to him if he had not contracted that infection,” said Sandy Riley, 61, of Swissvale. She instigated a claim over the Legionnaires’-linked death of her brother, Lloyd “Mitch” Wanstreet, 65, of Jeannette and hopes to inspire some accountability, she said.
“These things never should have happened if they had maintained their systems properly,” Riley said.
The Nicklas complaint echoes that argument and makes several others, claiming the VA failed to control Legionella bacteria that cause the disease. The VA failed to give William Nicklas appropriate treatment and to test patients adequately for Legionnaires’ disease, among many failures, according to the lawsuit.
Read more: http://triblive.com/news/adminpage/4468137-74/nicklas-disease-government#ixzz2awxsCjQj
Follow us: @triblive on Twitter | triblive on Facebook
WASHINGTON, DC – Today, Chairman Jeff Miller (FL-01) and American Legion
Do you really need to be licensed as a physician to get a physician’s performance bonus at the VA?
Of course not!
While there are many doctors and dentists at the VA who work hard, do a great job and deserve every penny of their salary and bonuses, there are a few who do not. The GSA has concluded that the VA’s leadership has not implemented its “performance bonus program” in a manner that is either consistent or actually rewards doctors for their performance.
The GAO found that the VA gave$11,189 to a surgeon :
“..who was supervising residents left the operating room and medical center before the surgery was completed, allowing residents to continue the surgery without supervision until another surgeon was found to supervise the residents. The surgeon was suspended without pay for 14 calendar days.
The VA gave $8,216 to a radiologist that a Professional Standards Board found failed to read mammograms and other complex images competently.
The VA gave $7,500 to a physician who was reprimanded after the physician refused to see assigned patients in emergency room because physician believed patients had not been triaged appropriately by the emergency department nurse. As a result, wait times increased. According to documentation provided by the medical center, 15 patients waited more than 6 hours to be seen, and 9 patients left without being seen.
The VA gave $10,529 to a physician could not be reached when he was required to be available, which delayed patient care. Physician engaged in inappropriate behavior that had a negative impact on the patient care environment. The physician “yelled” at other staff, and the outbursts were regularly witnessed by patients, contributing to an atmosphere of fear and poor morale in the emergency department. The physician was suspended for 3 days with pay and received a letter of alternative discipline
The VA gave $7,663 to a doctor who practiced for three months without a license.
Tampa VA Surgeon Arrested for Illegally Obtaining Drugs
Richard L. Carpenter an ears nose and throat surgeon has been arrested in Tampa, Florida for illegally obtaining prescription medicine. So far the VA appears not to have issued any explanation for this incident and not much information is available about Carpenter. According to the American Board of Otolaryngology website, he was certified as an ear, nose and throat surgeon in 1985. He was certified prior to mandatory re-certification and has not been re-certified since 1985. Until recently he practiced in Michigan as part of Mid-Michigan Ear, Nose & Throat PC. He is pictured in their current group picture, but his profile has been removed.
Read more about this on our crimes page!
ALBUQUERQUE — Dr. Frank Allen Zimba has been practicing medicine for 31 years, is board certified in neurological surgery — and has a disciplinary history in two other states of operating on the wrong part of his patients’ spines.
The 57-year-old Texas native was hired at the Veterans Affairs hospital in Albuquerque last August, even though disciplinary proceedings that resulted in a suspension of his Oklahoma medical license were pending.
The VA in Albuquerque isn’t saying whether Zimba has had any problems on the job so far — claiming it would be a personnel matter. But even if there have been, the state Medical Board has no jurisdiction to investigate.
That’s because under federal law Zimba is not required to be licensed in New Mexico, unlike most other physicians who work here. He only needs to be licensed in one state in the country, and he has licenses in Oklahoma, New York, Michigan and Pennsylvania.
That left Zimba — who, through a VA spokeswoman, declined to be interviewed for this story — able to work at the Albuquerque VA Hospital during the six months his Oklahoma license was suspended.
Disciplinary records show Zimba was suspended for allegedly operating on the wrong part of a patient’s spine in February 2010. The suspension ended in March of this year.
Several years earlier, he was alleged to have performed surgery on the wrong side of two patients’ spines at a hospital in Jamestown, N.Y.
“They call it a never event,” said Oklahoma assistant attorney general Libby Scott, because it should never happen if hospitals follow procedures and properly mark the sites for surgery.
We will also be posting other information about crime, fraud and other things that adversely affect the quality of medical care that veterans receive from the VA, so if you have any information about medical malpractice at the Veterans Administration, or by a VA doctor, nurse or other health care provider please let us know about it.
The information on this web site is designed to encourage a discussion about Veterans Administration medical malpractice, malpractice claims and procedures. It is not intended to be legal advice. Legal advice can only be obtained from an attorney. If you have a medical malpractice claim against the Veterans Administration, you should consult with an attorney who is familiar with handling medical malpractice claims against the Veterans Administration and the Federal Tort Claims Act.
In the event that you have a Veterans Administration medical malpractice claim, you should immediately seek representation from an attorney who is experienced with litigating medical malpractice cases against the Veterans Administration or the VA.