Trouble in Tennessee! VA OIG confirms that malpractice at the Memphis VA emergency room contributed to the deaths of 3 veterans!

Trouble in Tennessee! VA OIG confirms that malpractice at the Memphis VA emergency room contributed to the deaths of 3 veterans!

VA OIG confirms that medical malpractice in the emergency department at the Memphis VA contributed to the deaths of 3 veterans.More information about this and other medical malpractice at veterans affairs hospitals and lawyers who handle medical malpractice cases against the VA for veterans at

VA OIG confirms that medical malpractice in the emergency department at the Memphis VA 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:

VAOIG-13-00505-348 Emergency Department Deaths Memphis VA

Veterans protest plans to tear down buildings at FDR Veterans Hospital in Montrose

Veterans protest plans to tear down buildings at FDR Veterans Hospital in Montrose.

Veterans protest plans to tear down buildings at FDR Veterans Hospital in Montrose

The veterans say they are alarmed that VA officials are planning to tear down five buildings on the 192-acre complex next year. They fear it’s part of a larger plan to demolish and dismantle the facility. (10/23/13)

MONTROSE – Dozens of veterans protested outside of a VA hospital in Montrose today over the possibility that some of the buildings on the property could be torn down.

Al Donohue was part of a small army of veterans and politicians rallying outside the FDR Veterans Hospital with the mission of saving the medical facility.

“It’s the only place for guys that get wounded that have head injuries. This is what they are treated for,” Donahue says. If they close this place down, they will have no place to go.”

The veterans say they are alarmed that VA officials are planning to tear down five buildings on the 192-acre complex next year. They fear it’s part of a larger plan to demolish and dismantle the facility.

VA officials tell News 12 that there are no plans to dismantle VA or reduce any services there. They insist the buildings they are tearing down have been vacant for decades and are no longer safe.

Officials say they plan to demolish the buildings next summer.

VA halts new spending on criticized ad campaign | Military Times |

VA halts new spending on criticized ad campaign | Military Times |

A key lawmaker is pressing the Veterans Affairs Department to cancel $5 million in television and radio advertising, saying the expense seems inappropriate at a time when the almost 10,000 VA workers are furloughed and there is concern about whether veterans will receive Nov. 1 benefits checks.


He’s too late — the ad campaign has already ended.


Rep. Jeff Miller, R-Fla., chairman of the House Veterans’ Affairs Committee, said in a Oct. 14 letter that the expense of ad campaigns in 20 media markets over the past six weeks are “ill-timed” and suggests VA “redirect” the money toward “higher priorities.”


But VA officials said the ads, purchased in early September, ended last weekend after their scheduled six-week run.


Miller complained the advertising, aimed at encouraging veterans to check out VA resources and benefits, is “counterproductive” because the partial government shutdown that began Oct. 1 at the start of the fiscal year has reduced VA services.


Veterans seeking services “may find the agency unresponsive,” he said. For example, an advertisement mentions the GI Bill as a benefit available to veterans, but anyone calling VA to ask questions about the education program will find that nobody is answering the toll-free line.


Miller had earlier raised questions about $1 million in VA spending on advertising in the Washington, D.C., metropolitan area. But his staff later found similar ads in Atlanta, Dallas, Detroit, Honolulu, Los Angeles, San Diego, and 14 other markets purchased at the end of fiscal 2013 with existing funds and scheduled to run over about six weeks.


The markets were chosen because of their large veterans populations and low rates of VA health care enrollment, officials said.


Congress and the White House are working on a debt and spending agreement that could end the government shutdown as early as Thursday. VA could not launch another ad campaign until funding is provided.


VA spokeswoman Victoria Dillon said the ads are part of a comprehensive outreach campaign “in an effort to inform veterans of the benefits and services they have earned and deserved.”


The funds came from appropriations that were going to lapse at the end of last fiscal year, Dillon said.

Legionnaires’ disease water restrictions back in place at VA Oakland | TribLIVE

Legionnaires’ disease water restrictions back in place at VA Oakland | TribLIVE.

Water restrictions are in place at the Veterans Affairs hospital in Oakland because officials found “a small amount” of the bacteria that causes Legionnaires’ disease.

A Legionnaires’ outbreak at that facility, first disclosed 11 months ago, lasted almost two years and sickened at least 21 veterans, five of whom died. As congressional and internal VA investigators probed the outbreak, administrators implemented more stringent testing standards for the Legionella bacteria — standards that VA spokesman David Cowgill credited with detecting the bacteria on Oct. 7.

“Because of the hyper-vigilance demonstrated by our updated surveillance program, we immediately performed shock chlorination on both the hot and cold plumbing loops” of the hospital on University Drive, Cowgill said.

Cowgill declined to specify where in the building the bacteria were found or how much of the hospital is affected by the water restrictions, offering only that it was in “a limited number of (plumbing) fixtures.”

The restrictions at the hospital won’t be lifted until tests show the bacteria are gone. That could take as long as two weeks, he said.

“On Oct. 7, we talked individually to each of the veterans hospitalized in this building, or their families, to let them know about the situation,” Cowgill said. “Our goal is to minimize any inconvenience to veterans, family members and staff. Only this one building at our University Drive campus is affected.”

Testers measure Legionella in “colony forming units,” or CFUs. National VA guidelines say hospitals should use tests that can detect as few as 10 CFUs per milliliter of water. In the months after the outbreak, the VA Pittsburgh announced a zero-tolerance approach in which even one CFU triggers decontamination procedures.

Cowgill declined to specify the CFUs detected but said it “would not have been found by most commercial laboratories.” That suggests — though does not confirm — that the Legionella count was below the 10 CFU threshold.

Administrators restricted water usage at the VA’s O’Hara hospital campus in August after the bacteria was found in a patient’s room there. Cowgill said then that the concentration was 7 CFUs per milliliter.

Mike Wereschagin is a staff writer for Trib Total Media. He can be reached at 412-320-7900 o

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Veterans Affairs Committee chairman: Accidental overdoses at VA “not acceptable” – CBS News

Veterans Affairs Committee chairman: Accidental overdoses at VA “not acceptable” – CBS News.

For the last month, we’ve been reporting on the consequences of this, including accidental fatal overdoses. This week we sat down with Congressman Jeff Miller, who chairs the House Veterans Affairs Committee.

Miller, a Republican from Florida, expressed his concern over the ratio at VA between pain management specialists and suffering veterans.

“You’re talking about 2 providers per 100,000 veterans,” said Miller. “I don’t see how they can in anyway think that they’re able to manage this particular part of the pain management of our veterans.”

Miller called the situation “not acceptable.”

“Unfortunately, it has become a routine way of dealing with our veterans, and I don’t think America expects their veterans to be given prescriptions only to mask the feeling of pain and not help the veteran get better,” he said.

This week, Heather McDonald and Kimberly Green testified on Capitol Hill about their husbands Scott and Ricky, both veterans with chronic pain who accidentally fatally overdosed on prescriptions written and filled by VA providers.

“There have to be systemic changes made within VA, but you can’t just tell people to make those changes without some type of follow up,” said Miller. “Today, given the fact that there are pain-management specialists out there that can help the veterans deal with their pain without going through this heavy narcotic-prescription issue, I think that the veterans should have that opportunity. I wish I could guarantee, in fact, that it would never happen again, but there are no guarantees.”

The VA doctors at the hearing promised to make changes to restore trust. They were told by the hearing’s chairman to get him some ideas on how to do that within 30 days.


Memo: Delay in care harmed veterans at Augusta’s VA medical center – Atlanta Business Chronicle

Delays in getting 4,500 appointments at the Charlie Norwood VA Medical Center in Augusta resulted in patients being harmed, says an internal VA memo uncovered by the House Committee on Veterans Affairs, reports The Augusta Chronicle.

The committee is seeking more information about what happened to Augusta VA management as a result, and is specifically seeking more information on Rebecca Wiley, the Augusta VA’s former director, the paper said.

The committee is also asking for information on performance reviews, bonuses and disciplinary actions for other Augusta VA management and wants a current list of appointment backlogs, the paper said.

via Memo: Delay in care harmed veterans at Augusta’s VA medical center – Atlanta Business Chronicle.

How we analyzed the VA’s opiate prescription data | The Center for Investigative Reporting

How we analyzed the VA’s opiate prescription data | The Center for Investigative Reporting.


Through the Freedom of Information Act, The Center for Investigative Reporting received two data sets from the Department of Veterans Affairs: one showing the number of opiate prescriptions issued by the VA and the other the number of patients served at every VA hospital and clinic. The data covered the years since 9/11, from 2001 through 2012.

Using the unique regional and facility identifiers in the data, we combined the data and associated it with a map of facility locations from the VA. The IDs allowed us to group hospitals and clinics by system. We also created a map of the VA’s regional boundaries using a map of all U.S. counties, which became the backbone of our interactive map.

Although the prescription data came as calendar year totals while the patient data was aggregated by fiscal year, we were able to adjust the fiscal year patient counts to approximate the calendar year. This allowed us to calculate the rate of opiate prescriptions to patients served, making it possible to compare facilities of varying sizes and identify the hospitals and clinics with the highest rates of opiate prescriptions by year, by drug and over time.

In a small handful of cases, patient data was recorded by the VA in a way that likely overstates the number of patients served in a particular hospital system. We have noted this on our map with an asterisk. A few hospital systems also appear to prescribe far fewer opiates than expected, given rates across the country in similar locations, which might indicate that the VA data is missing some information from those areas.

The results of our analysis can be explored through our interactive map.

Interactive map displays VA drug prescription rates

VA doesn’t know how nurse obtained fentanyl used in overdose death | TribLIVE

VA doesn’t know how nurse obtained fentanyl used in overdose death | TribLIVE.

Ten months since a Department of Veterans Affairs nurse overdosed on fentanyl, investigators have not determined where he obtained the narcotic pain medicine, Pittsburgh VA spokesman David Cowgill said.

Patrick Austin, 47, of Gibsonia died of the overdose Jan. 16 in the Oakland VA hospital, where co-workers discovered his body in a bathroom and apparently tried to perform CPR, authorities reported earlier.

Cowgill said on Friday he could not comment on how long Austin might have been using fentanyl, citing federal privacy restrictions.

Austin worked since June 2007 in the VA Pittsburgh Healthcare System. A joint investigation involving VA and Pittsburgh police and the VA Office of Inspector General turned up no evidence that Austin had obtained the fentanyl inside the hospital, Cowgill said.

City police Lt. Daniel Herrmann said authorities found no evidence of criminal conduct and termed Austin’s death an accident.

“The situation was thoroughly investigated, and the case is closed,” Cowgill wrote in an email message. “There is no other investigative effort planned.”

He said the Pittsburgh VA is providing improved training to supervisors “so that they can better recognize signs and symptoms of employees who might be suffering from substance abuse problems.”

He identified no other internal changes as a result of the fatality.

Government health officials approved fentanyl in 1990 to ease severe or chronic pain, according to the Centers for Disease Control and Prevention in Atlanta. Austin’s death is attributed officially to toxic effects of the drug.

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Pittsburgh VA ranks in top 10 for privacy complaints | TribLIVE

More good news from Michael Moreland  & VISN  4!

Pittsburgh VA ranks in top 10 for privacy complaints | TribLIVE.

On Jan. 4, 2010, a woman showed up to work at the VA Pittsburgh Healthcare System.

She had not submitted a resumé to the Department of Veterans Affairs or received a notice of hiring from the human resources department. She didn’t have an official ID tag or a password to enter the nationwide computer system.

“Hired” by a friend employed at the VA Pittsburgh, she spent six weeks registering patients, issuing wristbands, scheduling appointments — and handling the sensitive medical and financial records of up to 6,207 military veterans. Her friend and other employees for whom she filled in gave her their passwords.

The scheme fell apart about a month later when the unnamed woman asked HR “why she had not received a paycheck,” according to a VA security report the Tribune-Review obtained.

The incident triggered the VA’s second-largest breach of protected data nationwide in three years, potentially compromising data for about one in 10 patients.

According to the VA memo, the woman had worked as “a healthcare professional at a local hospital.”

The VA offered free credit monitoring to veterans whose records she read. Employees embroiled in her hiring faced “appropriate disciplinary action,” but there was no indication anyone would be fired.

Though the VA by law must disclose privacy breaches affecting more than 500 patients to the Department of Health and Human Services, officials there told the Trib that the VA failed to alert them.

A spokesman for Terry Gerigk Wolf, who has led the VA Pittsburgh Healthcare System since 2007, and her boss, Michael Moreland, director of Veterans Integrated Service Network 4, referred the Trib’s written questions about their handling of this and other privacy complaints to the VA’s national headquarters in Washington.

A VA spokeswoman there said Pittsburgh administrators decided not to tell Health and Human Services because they determined there was low risk of misuse of the data.

The fake employee was one of 267 Pittsburgh VA privacy failures from Jan. 1, 2010, to May 31, 2013. Medical or financial records for at least 7,069 vets and seven workers were lost, stolen or disclosed to outsiders, according to reports to the national office.

The Pittsburgh VA was in the top 10 nationwide for the number of complaints and second for the total number of potential victims since 2010.

Privacy problems appear to continue. An April 18 report claims an unidentified whistle-blower compiled seven binders of data on 14 patients — four of them deceased — to try to “prove lab equipment is faulty.”

That violates federal health privacy rules, but the Trib wanted to know if patients should worry about unsafe medical lab equipment. VA officials declined to comment.

New safety fears follow ongoing congressional probes dogging the Pittsburgh VA over one of the largest backlogs of benefits claims nationwide and an outbreak of Legionnaire’s disease between 2011 and 2012 linked to at least five deaths.

“The problems you see are caused by a VA that threatens no consequences for wrongdoers, provides no oversight and fails to properly monitor employees for privacy violations,” said Darin Selnick, a former high-ranking VA official who advises Concerned Veterans for America, a Washington-based advocacy group.

“There’s a problem with the culture at VA. It’s degraded over the years, management is too lax, and real power isn’t even held by the central office in Washington but by unaccountable hospital fiefdoms like you see in Pittsburgh. And no one can stop them,” said Selnick, a retired Air Force officer.

“Want to solve the problem? Start visibly firing them for these sorts of privacy violations. That sends a signal to the entire VA workforce about standards.”

Carl Prine is a Trib Total Media staff writer. Reach him at 412-320-7826 or

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