More than 500 military veterans died because of serious mistakes at Veterans Affairs hospitals across the country between 2010 and 2014, VA records show.
There were a total of 1,452 "institutional disclosures of adverse events" between fiscal years 2010 and 2014, 526 of which resulted in patient deaths, according to VA data obtained by the Washington Free Beacon through a Freedom of Information Act request.
According to the Veterans Health Administration, such disclosures are required when "an adverse event has occurred during the patient’s care that resulted in or is reasonably expected to result in death or serious injury."
Specifically, adverse events are defined by the department as "untoward incidents, diagnostic or therapeutic misadventures, iatrogenic injuries, or other occurrences of harm or potential harm directly associated with care or services provided" by the VA.
The 1,452 disclosures represent a miniscule portion of the hundreds of thousands of patients who are treated annually at VA hospitals, but they reveal for the first time a fuller picture of errors and lapses in medical coverage that affect veterans across the country.
The disclosures include feeding tubes being placed in patients’ lungs, patients being sent home with undiagnosed rib and shoulder fractures, and in one case extracting the wrong tooth from a patient.
But buried among the more common mistakes that occur in even the best hospitals—incorrect dosages, surgical equipment accidentally left in patients’ bodies—are reports of the fatal delays in cancer diagnoses and follow-up treatments that would later lead to a national scandal and the resignation of the VA Secretary.
"Chest X-Ray for [patient] showed an ill-defined one centimeter nodule overlying the left anterior fourth rib," a 2011 entry from a San Diego VA hospital reads. "Radiology recommended a CT scan of the chest for a more complete evaluation of possible left midlung nodule. Patient was not informed about abnormal imaging and no follow-up was arranged. Patient was seen in the ER six months later. Patient diagnosed with Stage IV small cell lung cancer and passed away two months later."
"[Patient] had chest X-ray in 2010; no follow-up until patient presented for ER visit in 2010," another entry from Erie, Pennsylvania reads. "Patient ultimately found to have lung cancer. He expired in 2011. A delay in work-up of approximately 6 months occurred."
"Follow-up CT scan ordered at CBOC to be completed at parent facility. Order faxed to unmanned printer and it did not get scheduled. Delay of diagnosis of lung cancer of approximately 9 months."
Scores of similar entries are scattered through the quarterly reports from every corner of the United States, from Puerto Rico to Fargo to Los Angeles.
In fiscal year 2012 alone, 74 patients with some form of cancer saw delays in their treatment or the initial findings were overlooked. Twelve of those veterans ultimately died from their illness.
Less frequent but equally troublesome are reports of VA staff not properly screening patients at risk for suicide.
"Missed Opportunities prior to Suicide Completion" is the entirety of one entry from 2011.
Medical privacy laws strictly bar from disclosure the names of patients and other details, making it difficult to document individual cases, but the data does show general trends. Reports of patient deaths and injuries rose steadily from 2010 to 2013, peaking with 126 reported deaths.
As U.S. troop drawdowns in Iraq and Afghanistan accelerated over those years, VA hospitals struggled to handle the surge in patients and simultaneous shortage of doctors and staff. Some did the best they could under the circumstances, but other hospitals turned to dishonest means to hide the scope of the problem from VA headquarters in Washington.
VA Whistleblowers first began coming forward in late 2013 with allegations that schedulers at the Phoenix VA hospital used secret paper waiting lists to hide the long wait times faced by patients. Whistleblowers alleged that up to 40 veterans died while their requested appointments languished on unofficial paper lists.
The VA disclosed in April that, since 1999, 76 patients nationwide were seriously injured because of delayed gastro-intestinal cancer screenings, and 23 died.
A May audit of the Phoenix hospital found 1,700 patients were put on unofficial wait lists and subjected to treatment delays of up to 115 days.
VA Secretary Eric Shinseki resigned as a result of the scandal, and the department ordered a nationwide audit of its consulting practices.
That audit released in June, found that 57,436 newly enrolled veterans face a minimum 90-day wait for medical care, while 63,869 veterans who enrolled over the past decade requested an appointment that never happened.
According to the audit, 8 percent of scheduling staff nationwide used something other than the official electronic wait lists, and 13 percent of staff had been instructed by a supervisor to enter a date other than the veteran’s requested appointment into the "desired date" field, fudging the actual wait times.
Since then, the new VA Secretary has fired five senior administrators at problematic VA facilities, including the director of the Phoenix VA hospital.
The number of patient deaths due to errors dropped to 107 in fiscal year 2014, according to VA records.
However, the widespread use of secret waiting lists means that there are potentially many more cases of patients who died because of long-delayed appointments than appear in the reports that were filed to VA headquarters. For example, the Phoenix VA hospital appears relatively few times in the reports, and no significant delays were reported there in 2013.
Columbia, South Carolina
The Williams Jennings Bryan Dorn Veterans Medical Center in Columbia, South Carolina reported the highest number of delays in cancer care, of any facility, in 2012.
The cancer care of at least eight veterans was delayed significantly enough that officials said it may have impacted the rate of survival and the ability to later provide sufficient treatment.
Four disclosures note that a "delay in diagnosing impacted [the veteran’s] cancer staging and survival rate." Four others use similar language, explaining that delays "in diagnosis impacted… cancer staging and treatment" of the patients.
The Dorn facility first came under scrutiny for delays in cancer care, specifically gastrointestinal (GI) care, following a CNN report in November of 2013.
The facilities’ own disclosures show that delays in gastrointestinal care have plagued the facility for a number of years.
In 2013, nine patients experienced delays between their initial consultation and necessary diagnostic procedures, such as endoscopies and colonoscopies.
The delays in GI care for two veterans, in 2012, meant they were required to undergo surgery to remove a mass in their colon, which "might have been removed endoscopically" instead of surgically if the procedure was completed earlier.
There have been six total deaths since 1999 due to delayed cancer screenings, according to the VA report.
A February report by the VA Inspector General found the Dorn hospital faced staffing and equipment shortages that led to delays. The report also noted that Dorn ranked 127th out of 128 VA facilities in health care-associated infections during 2013.
In response to the report, the Dorn VA hospital said it was immediately taking steps to fix the problems.
The Dorn VA hospital did not immediately return requests for comment.
The Malcom Randall VA Medical Center in Gainesville, Fla., reported 31 "adverse events" during fiscal year 2013, the most of any VA facility. Three of those incidents were delays in cancer diagnosis and treatment.
The VA also confirmed earlier this year that two patients died at North Florida/South Georgia system, where the Gainesville hospital is located, due to delayed cancer screenings.
Additionally, the hospital conducted an "incorrect autopsy," according to a 2013 disclosure.
The system is the busiest in the country, serving roughly 125,000 VA patients per year. However, numerous congressional investigations and internal audits by the VA also describe a corrosive work environment, where leadership encouraged staff to cook the books to meet performance standards and where whistleblowers were harshly punished.
Three VA officials in Gainesville were placed on leave this year after an audit by the VA Inspector General found the hospital was using a secret paper list to keep track of appointments.
There were also allegations that surgeons were not allowed to perform certain operating room procedures to avoid increased mortality rates, and that patients with a high mortality risk were sent to a local hospital. However, the VA Inspector General said in a report it could not substantiate those claims.
The Charlie Norwood VA Medical Center in Augusta, Ga., reported 14 "adverse events" during fiscal year 2013, and three cancer patients died as a result of delayed screenings over the past two years.
In 2013 alone, there were ten reports of delayed colonoscopies, two of which resulted in patient deaths.
According to a 2012 report from the VA Inspector General’s Office, five patients died or sustained serious injury as a result of mismanagement between 2007 and 2010, and more than 4,500 gastrointestinal endoscopy consults went unresolved.
A VA audit this year reported that 26 new patients in Augusta had to wait at least 90 days for an appointment. Additionally, 133 veterans were not scheduled for an appointment despite requesting one in the past 10 years.
Since then, Augusta officials say they have reduced the number of veterans waiting at least 90 days for an appointment from 26 patients to two.
There were four open federal investigations into whistleblower retaliation at the hospital as of July.
‘Missed opportunities prior to suicide completion’
Twenty-two veterans are said to commit suicide each day, and decreasing that number has become a key mission of the VA. However, some disclosures raise questions about the steps being taken inside the department’s facilities to ensure veterans receive appropriate attention for mental health issues.
"[Registered nurse] documented patient had frequent thoughts of suicide," one 2011 entry reads. "RN did not perform a suicide risk assessment with the patient and the patient attempted suicide by overdose."
"Providers did not listen to patient complaints that psychiatric meds not working," a 2012 report from a Salt Lake VA hospital said. "Patient overdosed on acetaminophen."
In one case, the family of a veteran reached out to staff at the facility in Albuquerque, New Mexico after they became concerned with the patient’s depressive behavior, but staffers failed to follow up on those concerns.
"Patient attempted suicide by stabbing with a knife to his neck requiring emergency surgical repair," the report notes. "Family had contacted facility with concern of patient depression behavior on [redacted]; lack of appropriate follow-up and medication regime."
In Saginaw, Michigan a veteran "on a day-pass from an inpatient PTSD treatment facility" died after ingesting medications prescribed by his primary care doctor without a "face to face assessment."
He was found dead in a motel room, two days after receiving the prescription, from "an accidental or intentional overdose of medications."
How common are deaths due to medical error in hospitals?
There are several caveats to the VA data. In many cases, the "adverse events" occurred from one to several years prior to the year they were reported. Many patients were also injured in falls or other accidents that were not strictly the result of staff error.
In other cases, the VA was scrupulous in reporting events that could not be conclusively connected to the death of a patient, some of whom had other severe medical problems.
Sometimes the mistakes did not even result in an injury. For example, in fiscal year 2013, 67 patients suffered no injury despite an error requiring a disclosure. Even in cases where the VA reported a mistake, some patients were still grateful for the care they received, according to the reports.
Although it is difficult to make a direct comparison without more detailed information, VA hospitals are not alone in committing serious, sometimes fatal mistakes.
According to a 2010 Department of Health and Human Services Office of Inspector General report, "an estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month."
In a groundbreaking 1999 study, the Institute of Medicine estimated that medical errors killed between 44,000 and 98,000 patients at hospitals nationwide every year. However the Journal of Patient Safety said in a report released last year that the numbers may be as high as between 210,000 and 440,000 patients each year.
Every year, an estimated 4,000 cases of "retained surgical items— in other words, things accidently left inside patients’ bodies—reported in the United States.
The Department of Veterans Affairs did not immediately respond to a request for comment for this article.
Stephen Gutowski contributed to this report.
Published under: Veterans Affairs