Supply issues delay procedures at DC VA hospital after officials claimed they stopped
Stars and Stripes April 12, 2018
WASHINGTON — Department of Veterans Affairs documents detail seven canceled procedures caused by supply shortages in February and March at the VA hospital in Washington, contrary to the agency’s claims that the last one was in January.
The documents, newly obtained by Stars and Stripes, outline seven instances of procedures being delayed or postponed because of supply shortages at the agency’s flagship hospital — four in February and three in March.
In one case last month, a 69-year-old veteran was under anesthesia and a surgeon made an incision for his hip implant before medical workers realized they didn’t have the correct supplies — nails for the implant were mismatched. The procedure was eventually completed, but the mix-up led to the veteran being under sedation 30 minutes longer than expected. The VA launched a patient safety report, and the incident will go under peer review.
The VA Inspector General’s Office issued early findings in April 2017 of its investigation into the DC hospital, which serves about 93,000 veterans, revealing widespread problems that put veterans at risk. Inspectors found multiple procedures that were canceled because of a lack of supplies.
In response to questions from Stars and Stripes about whether the problems were fixed, the VA claimed last week that the most recent canceled procedure because of supply shortages occurred in January. In that instance, the VA blamed delays at the Federal Express sorting station as the reason the hospital didn’t have the necessary supplies.
“The last canceled procedure due to equipment/supply shortages occurred in January 2018,” VA Press Secretary Curt Cashour said in a written statement last week.
In response to questions Thursday about the incidents in February and March, the VA claimed there were no procedures delayed or rescheduled because of a lack of supplies. Instead, Cashour argued six procedures were rescheduled during those two months because of “minor equipment sterilization issues.”
The House Committee on Veterans’ Affairs is aware of cases of canceled procedures at the DC hospital after January, said Tiffany Haverly, committee spokeswoman.
“The committee has received evidence of and is investigating canceled procedures in January, February and March,” she said.
According to a VA list of canceled procedures at the hospital, three dental procedures were delayed at the hospital in February because of unavailable supplies. One procedure was postponed for two weeks. Another was pushed back 48 days, and the other 51 days.
A colon surgery was canceled in February because of missing supplies and rescheduled for the following day.
VA reports show that problems with supply shortages at the DC hospital continued into March.
In one case last month, a 54-year-old veteran arrived at the hospital for a hip replacement. While he was in the waiting room, medical workers discovered their equipment wasn’t sterile. The procedure was rescheduled for the following week.
Another day in March, the hospital scheduled nine veterans for the same outpatient procedure but had only enough supplies for seven. A 69-year-old veteran had his appointment rescheduled for a later date. An 80-year-old veteran chose to wait for equipment to be sterilized, and he had his procedure later the same day.
The VA said a “communication breakdown” contributed to the shortage, as well as the heavy workload on the department responsible for sterilizing medical supplies.
According to a report from January, the VA’s National Program Office for Sterile Processing found key staff vacancies in that department. Cashour said last week that the hospital had hired nine additional permanent staff members for the team.
On March 26, the hospital’s medical supply vendor failed to make a delivery — leading to “critical medical supply shortages,” according to a report. Hospital leadership was notified, and supplies were pulled from other departments for time-sensitive surgeries.
The situation prompted the hospital to find backup vendors that could provide emergency medical supplies in case it happens again.
The instances of supply shortages and canceled procedures in the past two months are analogous of problems the IG described one year ago, indicating the issues persist at the DC hospital — located just four miles from VA headquarters — despite recent claims from the VA of substantial progress.
In a more comprehensive report the IG released last month, inspectors cited multiple incidents in 2017 when staff had to leave the medical center to borrow supplies from a private hospital across the street.
Inspectors reviewed 39 cases of canceled procedures because of supply shortages from 2015 to 2017. In some cases, veterans were unnecessarily hospitalized overnight because they were waiting for supplies. Surgeons sometimes were forced to use instruments that were available, instead of the ones they preferred, the IG reported.
Inspectors found no evidence that patients were harmed because of the lack of supplies, and they credited staff who “worked around these challenges and improvised as necessary to provide veterans with the best possible services under the circumstances.”
The IG and the Office of Special Counsel would not confirm whether they are investigating continued shortages and canceled procedures at the hospital.
The House Committee on Veterans’ Affairs is planning an oversight hearing as early as next month.