Did you think that medical malpractice was a new problem at the VA? | Veterans Administration Medical Malpractice Information

Classic studies and reports about medical malpractice at the VA. If you think that medical malpractice, reusing disposable medical supplies that can’t be sterilized, doctors without the proper qualifications, delays in scheduling appointments are new developments at the Department of Veterans Affair, then read some of these “classics.”

Identifying Physicians With License Sanctions An Incomplete Process

Since 1985, GAO and the Department of Veterans Affairs’ (VA) Office of
Inspector General have found many deficiencies in VA medical centers’
quality assurance programs designed to ensure that veterans
receive high-quality health care. These deficiencies occurred because
medical center personnel did not consistently identify and correct
quality-of-care problems. VA generally agreed with the review findings and
said it would improve its policies, procedures, and practices. However,
follow-up reviews have found many of the same problems.
In an April 2,1991, letter, the Chairman of the Senate Committee on
Veterans’ Affairs expressed concern that VA has not developed an effective
approach to address key quality assurance issues. He requested that GAO
monitor VA’S efforts to strengthen its health care quality assurance
programs and provide a perspective on the likely impact of recent and
proposed changes to its quality assurance program.
This report focuses on three quality assurance problem areas that GAO and
the Inspector General have identified in recent years, and the efforts VA
has made to resolve them. These areas are (1) inadequate reporting and
investigation of patient incidents, (2) failure to properly document the
supervision of resident physicians, and (3) incomplete review and
documentation of physician credentials and privileges. The report also
discusses initiatives VA is undertaking to strengthen its quality assurance
program

152914Medical Centers Are Not Correcting Identified Quality Assurance Problems 1992a

1992 Study by GAO finds that VA has not fixed medical malpractice mistakes that it identified in 1985

U.S. OFFICE OF SPECIAL COUNSEL TRANSMITS REPORT OF INVESTIGATION IN RESPONSE TO WHISTLEBLOWER’S ALLEGATIONS OF INADEQUATE ANESTHESIA CARE AT CARL T. HAYDEN VETERANS AFFAIRS MEDICAL CENTER, PHOENIX, ARIZONA

FOR IMMEDIATE RELEASE – 4/13/00
CONTACT: JANE MCFARLAND
(202) 653-7984

The U.S. Office of Special Counsel (OSC) today transmitted to President Clinton and the Congress, an investigative report from the Department of Veterans Affairs (VA), into whistleblower allegations of a substantial and specific danger to public health and safety at the Carl T. Hayden Veterans Affairs Medical Center (VAMC), Phoenix, Arizona.

The VA investigation was triggered by a disclosure made to the OSC by Winston Liao, M.D., a physician anesthesiologist at the VAMC. Dr. Liao alleged that he observed an extremely high rate of complications occurring in patients under the care of a particular Nurse Anesthetist. He alleged that this individual falsified medical records by pre-recording patient’s vital signs during the administration of anesthesia, and that he left patients unattended during procedures. Dr. Liao claimed that the Nurse Anesthetist’s behavior caused at least four patient deaths, and resulted in the collapse of at least eight patients after surgery. Dr. Liao also asserted that the Nurse Anesthetist had been involved in nearly 200 cases of serious injury or death as a result of his incompetence.

The OSC found that Dr. Liao’s disclosures demonstrated a substantial likelihood of a specific danger to public health and safety, and forwarded the allegations to the VA, directing it to conduct an investigation and provide a written report. The OSC sought written clarification and further investigation from the VA on several occasions, after receipt of the initial written report. The VA subsequently issued a final report addressing the allegations, and a supplemental report confirming the actions the VA has taken in response to Dr. Liao’s allegations.

The VA report partially substantiated Dr. Liao’s allegations. It found that the Nurse Anesthetist provided substandard anesthesia care in six of 14 cases over a period extending from 1993 to 1999. The report confirmed that the subject Nurse Anesthetist had incidents in the post-anesthesia care unit in numbers greater than the other five nurse anesthetists did. In six patients, according to the VA report, premature endotracheal extubation at the end of anesthesia appeared to be the primary problem. Of the 14 patients studied, three died. Despite its findings that several patients received substandard care, the VA report concluded that there was no evidence that the Nurse Anesthetist’s behavior caused these deaths. The report did confirm that the Nurse Anesthetist had behavioral issues, and was heard to speak about veteran patients in a deprecating, insulting manner.

On a broader scale, the VA report found that the VAMC lacked a plan and process to measure and assess data regarding anesthesia quality issues during the period from 1993 to 1999. The report also found that senior VAMC officials did not communicate serious concerns related to anesthesia and surgery upwards. The report found numerous weaknesses in the infrastructure supporting the surgical and anesthesia programs. Finally, the report found that officials at the VAMC violated the law by failing to provide proficiency rating for the Nurse Anesthetist since January 1997.

Based on the findings of the investigation, the VA represented that it has taken several measures to address the serious patient care issues raised by Dr. Liao: (1) standardized extubation guidelines are in place, and no further system-wide action is required; (2) the subject Nurse Anesthetist remains under appropriate supervision and performance monitoring by the Acting Chief, Anesthesia Section. The subject received a proficiency rating of highly satisfactory in January 2000; (3) a supervising Certified Registered Nurse Anesthetist has been appointed to assist in monitoring and to address learning needs of the group; (4) anesthesia staff members have completed an Airway Study, focusing on reintubation in the immediate post-operative period; (5) criteria for endotracheal extubation were developed and implemented by anesthesia staff at the Medical Center in September 1999; and (6) systematic data collection on performance measures in anesthesia began in June 1999 and continues.

The Special Counsel has determined, pursuant to 5 U.S.C. § 1213(e)(2), that the findings in the agency’s report contain all of the information required by statute, and that the findings appear reasonable except to the extent that the VA has not committed to take specific disciplinary or other appropriate action against individuals found to have provided substandard care to patients. The Special Counsel has recommended that the VA be encouraged to reexamine any policy or procedures that would permit or force the retention of such employees.

U.S. OFFICE OF SPECIAL COUNSEL ANNOUNCES FAVORABLE SETTLEMENT OF WHISTLEBLOWER COMPLAINT WITH VA MEDICAL CENTER

FOR IMMEDIATE RELEASE – 9/27/00
CONTACT: JANE MCFARLAND
(202) 653-7984

Today, the U.S. Office of Special Counsel (OSC) announced the favorable settlement of a complaint filed with it by a Certified Registered Nurse Anesthetist (CRNA). The CRNA, who asked not to be identified, alleged that the Department of Veterans Affairs (VA), Louis Stokes Medical Affairs Center (the Center), Cleveland, Ohio, took various actions against him culminating in his proposed removal, in reprisal for his disclosures about the clinical competency of certain Anesthesiologists with whom he practiced. As a result of the settlement, the agency rescinded the proposed removal, provided a lump sum payment, and will sponsor OSC-led prohibited personnel practice training for its employees. In exchange, the CRNA has resigned from this specific Center. The VA does not admit to any wrongdoing or liability.

Evidence obtained during OSC’s investigation revealed that the CRNA made protected disclosures throughout his tenure to his supervisors, Congressional representatives, and the VA Inspector General. It was his protected disclosures to senior officials of the University of Akron’s Student Registered Nurse Anesthetist program, OSC concluded, that formed the basis for his proposed removal. The CRNA reported two examples of potentially fatal medical errors by one Anesthesiologist whom he alleged was practicing beyond actual skill level while supervising student registered nurse anesthetists from the University. OSC’s investigation concluded that the CRNA reasonably believed that he was disclosing a substantial and specific danger to public health and safety.

In its proposal to remove him, the agency charged the CRNA, among lesser offenses, with violating the Center’s policy of requiring VA employees to report their concerns of irregularities occurring on VA grounds to appropriate VA officials and with making disparaging remarks about the Anesthesiology Service which resulted in the University’s withdrawal of its students from the Center.

VA hospitals skirt the law to employ foreign doctors

Tuesday, January 30, 2001

By JOAN MAZZOLINI

PLAIN DEALER

Cleveland, Ohio

VA hospitals must justify hiring foreign doctors by showing the need is so great that a medical service would be severely affected or even stopped. But many were hired in part-time positions, a Plain Dealer review of VA’s hiring practices found.

The VA says the U.S. Immigration and Naturalization Service endorsed those part-time hires, even though immigration laws allow foreigners to stay only for full-time jobs. However, INS officials said they weren’t aware that foreign doctors were being hired for part-time VA positions.

VA officials, who would answer questions only in writing, said that because U.S. doctors often look for more lucrative jobs, hiring foreign doctors “allows VA to hire exceptionally well qualified physicians who otherwise would not be available to care for veterans.”

But critics say veterans hospitals don’t always make the effort to find U.S. doctors, instead hiring foreign doctors who line up for VA jobs, in some cases just to legally stay in the United States. Other times, a university hospital official wants the VA to hire the foreigners who trained at the university.

Most of the VA’s part-time doctors spend the rest of their workweek at the better-paying affiliated medical schools and university hospitals.

But the practice causes a “brain drain” that weakens the medical care in the countries those doctors came from.

While many are excellent doctors, others have questionable medical educations. Also, critics say some of them can’t communicate well with their patients because of language and cultural differences……

…During a recent visit, Brown, who served in the Navy during the Korean War, said she asked the young doctor to repeat herself several times. “She could not speak English well enough.”

Brown’s feelings are not unique.

“There were times over the years that a patient would have a problem, primarily a Vietnam-era vet would have a hard time relating to someone with an Asian background,” said Dr. Steve Cohen, director of the Dayton VA, where more than half of the staff’s nearly 90 doctors are foreigners.

Language problems surfaced in a Denver courtroom a few years ago.

In 1995 a federal judge found that the VA botched its care of veteran John Deasy and awarded him $4.5 million. They judge determines that language problems contributed to the bungled treatment.

Deasy was tied down, drugged, and locked down over several years’ time because of a medical condition that caused psychiatric symptoms. Experts testified that Deasy’s fear of maltreatment worsened his psychiatric problems. Federal Judge Jim R. Carrigan agreed.

“Mr. Deasy has been treated by a platoon of VA doctors, each taking his turn for no apparent reason other than the fact that he happened to be on call when this patient needed care,” the judge wrote. “Indeed, one of the physicians who treated Mr. Deasy spoke English so poorly when testifying at the trial that both the court and the court reporter repeatedly had to interrupt his testimony to ask that he repeat more clearly what he had said.

“This doctor’s heavy accent and submarginal communication skills in court corroborated Mr. Deasy’s testimony regarding his frustration when trying to explain that his problems were physical and not just psychiatric.”

LA Times Article on a Pathologist Dr. Dennis Hooper, Who Worked at the Reno, Nevada VA Hospital- The VA Had More Than 300 of His Cases Reviewed by the Armed Forces Institute of Pathology. The AFIP Found Mistakes in More Than a Third of the Cases, Yet the VA Never Advised the Nevada Medical Board.

One doctor’s long trail of dangerous mistakes
Alarmed colleagues reported pathologist Dennis Hooper to King/Drew officials, but he stayed on the job. Records detail sloppy work and faulty diagnoses even before he was hired.
By Tracy Weber and Charles Ornstein, Times Staff Writers
Five pathologists slipped into the microscope lab at Martin Luther King Jr./Drew Medical Center, steeling themselves to act after months of deepening suspicion.

They’d seen enough. They were convinced that their newest colleague, Dr. Dennis G. Hooper, was making dangerous mistakes. And on this August afternoon in 2000, they were prepared to turn him in.

Dr. Brian Yee had caught the first hint of trouble in April. Rechecking a 27-year-old man’s blood work, he noticed that Hooper, a pathologist with 16 years’ experience, had missed signs of leukemia.

Over the summer of 2000, the pathologists believed, Hooper had misdiagnosed at least four other patients.

One was Virginia Jackson, 75, known as “Mama Jackson” to her adoring 117th Street neighbors. In early July, Hooper had said she was cancer-free — having failed to spot the malignant cells in her urine.

Six weeks later, another pathologist, Dr. Theresa Loya, found invasive bladder cancer in a subsequent biopsy. The cancer would eventually kill Jackson, a mother of 16 and grandmother of 39.

About the same time, Dr. Hezla Mohamed was asked to recheck another of Hooper’s cases. Hooper had seen “no area of malignancy” in the swollen neck tissue of a 59-year-old man, medical records show. Mohamed suspected that it was thyroid cancer — a finding that an outside lab would later confirm.

At a certain point, “you start to wonder if the person knows what he’s doing,” said Mohamed, now pathology chairwoman at the Los Angeles County-owned hospital.

In the microscope lab that August day, Hooper’s colleagues worked out the details of a warning letter to the hospital’s chief medical officer and his associate.

The letter said Hooper, in his first six months on the job, had lost specimens and at times cut tissue so sloppily that he could not make an accurate diagnosis. It meticulously charted his alleged failings, listing each by case number, and cautioned that his work “puts all of us and the institution at risk for medical malpractice.”

Soon afterward, Mohamed recalled, the pathologists met with the hospital’s medical leaders, who said they would investigate the complaints and keep an eye on Hooper.

Further entreaties brought no response. Tension gave way to bitterness as the colleagues realized that this was the hospital’s final answer: silence.

“Here you had five pathologists signing a letter listing cases and telling administration in no uncertain terms that this pathologist has competency problems, and there was no response,” said Dr. Timothy Dutra, who signed the letter.

Worse than that, he said, the hospital’s medical leaders later denied ever receiving the letter, “even though I know it was given to them on three separate occasions.”

Hooper continued working, whipping slides through his microscope with a speed some colleagues considered irresponsible. The tall, paunchy pathologist, once eager for their friendship, kept more to himself now, listening to the music of Yanni on his headphones and saving his charm for their boss, Dr. Irene Gleason-Jordan.

Even when confronted with mistakes, some co-workers recall, Hooper seemed indifferent to the life-or-death importance of his job. Though pathologists rarely see patients in person, they issue crucial verdicts based on blood or tissue samples. Depending on a pathologist’s report, patients can return home to a normal life, require surgery and other treatment, or face the reality that their lives are ending.

Six months after the pathologists sent their letter, Johnnie Mae Williams, then 40, went to the public hospital in Willowbrook, south of Watts, for a seemingly minor gynecological exam. Hooper determined that she had cancer of the uterine lining, and surgeons quickly gave her a radical hysterectomy, taking out all of her reproductive organs.

Hooper was wrong.

He had seen cancer — but it wasn’t hers. His findings, it was later determined, were based on a slide from another patient, who had brain cancer. In his report, Hooper raised the possibility that the slide had somehow been mislabeled, but medical records show no evidence that he investigated where the slide came from.

When Mohamed examined Williams’ excised organs 2 1/2 weeks after her surgery, she found no evidence of cancer, according to Williams’ medical records.

A uterine-cancer expert said that what Hooper saw on the slides should have made him wary. The cancer that he diagnosed is uncommon in a woman of Williams’ age, and one cell type necessary for Hooper’s finding was absent, said Dr. Lora Hedrick Ellenson, a professor of pathology at Cornell University’s medical school, who reviewed Williams’ medical records for The Times.

“Everything about this case should have raised all kinds of red flags,” Ellenson said.

Mohamed informed at least five other doctors at King/Drew, including several involved in Williams’ care, that she did not have cancer, the records show.

But no one told Williams.

She did not learn of the misdiagnosis until more than two years later, when a Times reporter — unaware that she didn’t know — sought her out for an interview.

After the operation, “I felt like I wasn’t even going to be a full woman anymore,” she said, her hands shaking.

The mother of three had wanted to have more children. But she’d taken solace in being a cancer survivor, and she’d been grateful to King/Drew. “Everyone kept calling it ‘Killer King,’ ” she said. “I used to say, ‘No, that hospital saved my life.’ ”

Hooper, 55, has repeatedly declined to discuss the case and others cited in this article.

His attorney, James Andrew Hinds Jr., wrote in a Nov. 5 letter to The Times that the criticisms of Hooper amounted to “innuendo” and were “without factual substantiation.” In fact, he said, Hooper cleaned up “an administrative mess at the hospital.” Hinds also indicated that the doctor was precluded from commenting because of patient confidentiality rules.

As much as they scrutinized Hooper’s performance at King/Drew, his fellow pathologists knew little about his past. The same was true, apparently, of hospital officials.

Had they looked into it more closely, they might not have hired him in the first place.

An unseen cancer

When Roberta Nesbit got the results of her biopsy back from a San Diego lab in 1995, she had reason to celebrate.

The mole on her groin was benign, according to Hooper, who was filling in for another pathologist at the lab. She was cancer free.

Actually she wasn’t. Over the next 15 months, the melanoma would grow underneath her skin, becoming a massive tumor. She had a second biopsy, which revealed not only that she did have cancer, but also that it had spread to her lymph nodes.

Nesbit sued Hooper and the lab for malpractice.

In court papers, the pathologist’s own attorneys conceded that even a second-year medical trainee would have spotted the cancer in the mole. But Hooper, they said, was not at fault: He must have looked at a slide from another, healthy patient, mislabeled by a technician as Nesbit’s.

Nesbit’s attorney, who dismissed Hooper’s defense as specious, negotiated a $450,000 settlement with the doctor in 1998.

Less than a year later, Nesbit was dead at 57.

“We’re not talking about some trivial error here,” said Nesbit’s lawyer, Richard Binder. “We’re talking about something that cost someone her life.”

Hooper moved on. By late 1997, he was filling in at a Reno medical center operated by the U.S. Department of Veterans Affairs and tending to private medical laboratories he had opened in California, Nevada and Wyoming. (He eventually operated at least six, at various times.)

At the VA medical center, former co-workers remember him in rumpled khakis, singing along with Elvis recordings during autopsies or lamenting the ban on the diet drug combination fen-phen. He’d hurry through dissections and slides, then make phone calls related to his outside businesses, they say.

As at King/Drew, it wasn’t long before the quality of his work came into question.

In May 1998, a surgeon discovered that Hooper had failed to notice one of two tumors in a section of colon she had taken out, according to VA documents that The Times obtained through the federal Freedom of Information Act. Another pathologist determined the growth to be cancerous.

After a second physician expressed worries, Hooper was found to have made at least two more serious errors, VA documents show.

Ultimately, hospital administrators opened an investigation and sent slides from 346 of Hooper’s cases to the nationally renowned Armed Forces Institute of Pathology for a comprehensive review.

Of these cases, nearly a third contained mistakes. The institute found that Hooper had made major errors in 10 cases and minor errors in 104 more. Major errors typically require remedies such as chemotherapy or surgery.

According to a published study and two experts, the standard error rate for major mistakes by a general pathologist such as Hooper is less than 1% when all cases are reviewed.

Hooper’s rate was nearly three times that.

His contract as a fill-in at the hospital was not renewed, VA officials said.

“I would not hire him ever” again, said Dr. Paul Jensen, former chief of pathology and laboratory medicine at the Reno facility. “Wouldn’t even consider it.”

But the VA kept Hooper’s litany of mistakes to itself — never alerting the Nevada Board of Medical Examiners.

Dr. Thomas Barcia, the hospital chief of staff, said VA lawyers advised him that Hooper’s errors fell within acceptable industry norms.

To this day, if another hospital called to inquire about Hooper, the VA would give him a clean reference, Barcia said, adding that “the data I have does not show he was a substandard pathologist.”

In 1999, the year after the VA’s investigation of Hooper, another arm of the federal government sanctioned him for lapses in his private Reno laboratory.

The Health Care Financing Administration determined that Hooper had falsely claimed the lab was accredited by the College of American Pathologists. In fact, he had never applied for such accreditation, government records say…
LA Times Article