‘Highest levels of chaos’ impair D.C. veterans hospital, inspector general finds

At the main health-care facility for veterans in the nation’s capital, doctors have had to halt operating room procedures and dialysis treatments in the past year because of a lack of supplies, nurses have had to run through the facility looking for nasal oxygen tubes during an emergency, and sterile surgical items have been left in dirty or cluttered supply rooms, according to a new report.
Conditions at the Department of Veterans Affairs D.C. Medical Center were so troubling that the agency’s inspector general released a rare interim report Wednesday saying he is conducting a probe of the facility but did not want to wait for its completion to warn the public.
“We have not seen anything quite like this at a VA facility,” said Inspector General Michael J. Missal. “They have no inventory system. They don’t know what they have or what they are going to need.”
“Hospitals are typically chaotic places,” he told The Washington Post, “but this was the highest levels of chaos. Staff was literally scrambling every day. Sometimes they would have to go to other hospitals to get equipment as a procedure was going on.”
Missal said he also had a second motivation for going public: Investigators had determined that VA had known about some of the deficiencies for years, and therefore the inspector general had a “lack of confidence” that the agency would quickly address the problems.
The report had an immediate impact. VA placed the head of the medical center on leave Wednesday afternoon and brought in a senior agency official and additional staff.
“The department considers this an urgent patient-safety issue,” the agency said in a statement. “VA is conducting a swift and comprehensive review into these findings. 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.”
The Washington DC VA Medical Center, a sprawling campus along North Capitol Street and adjacent to the MedStar Washington Hospital Center, provides care to almost 100,000 veterans from across the region.