The Office of the Inspector General released an interim report on its ongoing investigation into patient safety issues at the Washington DC VA Medical Center. The report identifies "a number of serious and troubling deficiencies at the medical center that place patients at unnecessary risk."
The issuance of a preliminary report amid an ongoing investigation is rare and indicative of the seriousness of the safety issues detected by the OIG at the facility, according to USA Today.
"Although our work is continuing, we believed it appropriate to publish this Interim Summary
Report given the exigent nature of the issues we have preliminarily identified and the lack of confidence in Veterans Health Administration adequately and timely fixing the root causes of these issues," wrote Michael Missal, VA inspector general, in the interim report.
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Here are seven things to know.
1. The OIG's investigation into the D.C. facility began on March 29 and was initiated in response to a confidential complaint describing equipment and supply issues delivered to the OIG on March 21.
2. Key safety issues identified by the OIG at the facility include:
• No effective inventory detailing the availability of supplies and medical equipment used on patients
• No system to make sure medical equipment was subject to patient safety recalls
• Of the 25 storage facilities at the medical center examined by the OIG, 18 were found to be dirty
• In past year, more than $150 million in equipment and medical supplies had not been accounted for
• The lease for a warehouse used by the VA hospital containing unaccounted for equipment and supplies is set to expire with no plan to unload the storage space
• There are several vacancies at senior staffing positions that will make remediating safety issues identified by the OIG difficult to resolve
3. In response to the interim report, the VA appointed retired U.S. Army Colonel Lawrence Connell as the acting medical center director for the DC VA Medical Center on Wednesday. The move came after the VA initially appointed Charles Faselis, MD, the chief of staff of the D.C. facility, to the post earlier on Wednesday in the wake of the release of the OIG report.
"In naming Dr. Faselis as the acting director, VA was following a common line of succession," said the VA in a press release. "After further consideration, it was determined that naming an acting director from outside the facility would allow leadership to concentrate on addressing the many challenges identified in the OIG report, without compromising the ongoing internal review."
4. Since Jan. 1, 2014, the medical center has documented 194 patient safety events related to the availability of medical equipment or supplies, according to the OIG report.
5. The OIG recommends the Under Secretary for Health take immediate action to address the issues identified thus far in the investigation.
6. "VA is conducting a swift and comprehensive review into these findings," said the VA in a statement issued Wednesday. "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."
7. No adverse outcomes related to the safety issues at the facility have been identified at this time.
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