Three patients in a Veterans Administration (VA) hospital in Memphis died last year due to negligence by hospital staff, according to a report released last week, underscoring congressional overseers’ concerns about VA accountability.
Doctors administered drugs to one patient despite a documented allergy to it, leading to the patient’s death. Another was given a lethal dose of narcotic painkillers. A third died after hospital staff neglected to administer the proper medication.
The incidents, which took place at the Memphis VA Medical Center, mark the eighteenth preventable death at a Veterans Administration medical facility since 2011. Others occurred at VA facilities in Pittsburgh, Atlanta, and Columbia, S.C.
Rep. Jeff Miller (R., Fla.), chairman of the House Veterans Affairs Committee, blasted this "pattern of preventable veterans deaths and other patient-safety issues" in an emailed statement on Tuesday.
"It’s well past time for the department to put its employees on notice that anyone who lets patients fall through the cracks will be held fully responsible," Miller said.
A spokeswoman for the Veterans Affairs inspector general’s office (IG), which authored the report, said that its findings could result in legal action against responsible employees.
One patient—who, like all three examined in the report, was not named—checked into the Memphis facility with a "non-urgent" condition.
A nurse noted in the facility’s electronic health record (EHR) system that the patient was allergic to aspirin. A physician subsequently ordered and administered a drug known to cause a reaction in patients with aspirin allergies.
"The physician’s order … was hand-written rather than being entered into the EHR as required by local policy," the IG noted. "Entering the order electronically would have generated an alert that the medication was contraindicated due to the patient’s drug allergy.
The patient went into cardiac arrest an hour later. The patient died eight days later after the family opted to end life support.
Another patient was given a high dose of narcotics to ease extreme back pain. A nurse administered the drugs and left. Less than an hour later the patient was found unresponsive. He was resuscitated but entered a coma and died 13 days later.
An internal review noted that equipment designed to monitor the patient’s vital signs stopped reporting data five minutes after the nurse left the room. But the IG also noted that hospital staff were not "within hearing range" of the alert system, and "it was not connected to a centralized monitoring system."
A third Memphis patient, who had "a history of frequent hospitalizations and complex medical issues," was admitted after complaining about shortness of breath and eye pain.
An hour after being admitted, according to the IG, the patient reported being confused. That fact was never reported to the attending physician. The patient was subsequently found unresponsive and died the following day.
"His deterioration may have been prevented if appropriate antihypertensive medications had been given more aggressively," the IG found.
Internal investigations of the two doctors involved in the three incidents cleared them of wrongdoing.
A statement from the VA said it has already taken a number of steps to address the issues raised by the report.
"Memphis VA takes this issue very seriously, and has acted to address and correct issues directly contributing to the deaths, and continues to take steps to improve the care provided in our Emergency Department," the statement noted.
An official at the Memphis facility’s emergency department "reviewed the patient care provided by these physicians over a 6-month period [and] concluded that the physicians’ performance was satisfactory."
The VA also noted that one of the physicians in question no longer works at the Memphis facility.
The IG also recommended that the hospital’s facility director "confer with regional counsel for possible disclosure to the surviving family member(s) of patient 3."
That could lead to civil legal action by the patient’s family, the IG spokeswoman explained.
The larger IG report could also rekindle controversy over accountability among top VA officials.
The IG’s investigation into patient deaths at the Memphis VA facility began after complaints were filed with the office in October 2012. That followed an August 2012 IG report that found that the facility had not adequately addressed reports of excessive delays at its emergency department.
Reported problems in Memphis actually began in August 2011, when the IG received reports that patients were often left waiting in hallways on stretchers before being admitted.
James Robinson, then the director of the Memphis hospital, received a performance bonus of more than $10,000 for fiscal year 2011.
Observers have criticized large bonuses for other top VA officials who have presided over mismanagement at the administration.
"Like other hospital systems, VA isn’t immune from human error—even fatal human error," Miller told the Washington Free Beacon. "But what the department does seem to be immune from is meaningful accountability."
"Until VA leaders make a serious attempt to address the department’s widespread and systemic lack of accountability, I fear we’ll only see more of these lapses in care."