This lack of accountability is one of the main reasons that the VA system is in the shape that it is.
Full Article at: VA clinic troubles bring few penalties
Despite poor care in the Phila. prostate program, the agency has only slapped a few hands.
By Josh Goldstein
Inquirer Staff Writer
"More than a year after the Philadelphia VA Medical Center said it had given substandard care to nearly 100 veterans with prostate cancer, the list of sanctions is sparse:
One physician accepted a three-day suspension. A radiation safety official got a letter of reprimand. And the University of Pennsylvania doctor who performed most of the poor procedures lost his job when the Philadelphia VA closed the program.
Several lawmakers who have investigated the cases said that the Department of Veterans Affairs' actions were both anemic and late, and that the agency had acted only after prominent newspaper articles appeared in the summer, detailing radiation overdoses and underdoses.
"They ought not have to wait for a front-page newspaper article or a Senate committee hearing to do what they should have done on their own," said Sen. Arlen Specter (D., Pa.), one of the lawmakers who feels the VA has been slow to respond. "I think that it is regrettably necessary to keep pressure on them to follow up."
Newly obtained documents shed more light on the program, showing that the mistakes began with the earliest cases, starting in 2002, and that the hospital missed numerous opportunities to catch them.
In one 2003 case, for example, more than half the radioactive seeds landed in the patient's bladder instead of in the prostate. Yet no program-wide review ensued, and the brachytherapy treatments continued for five more years.
Gary Kao, the Penn radiation oncologist who directed the program, has been the public whipping boy for its flaws. He lost his VA position when the program was closed but was never officially sanctioned by the hospital. He's now on leave from Penn."
Monday, November 16, 2009
Calif. State Consumer Affairs Dept. Calls for Probe of Palo Alto-VA
Full Article at: State consumer affairs department requests probe of Palo Alto VA"
By Jessica Bernstein-Wax
Daily News Staff Writer
Posted: 11/14/2009 12:04:18 AM PST
Updated: 11/14/2009 12:04:19 AM PST
"The state consumer affairs department has formally requested an investigation into the VA Palo Alto Health Care System, where 23 glaucoma patients experienced significant vision loss while receiving treatment.
California Department of Consumer Affairs Director Brian Stiger made the request in response to an administrative petition the California Academy of Eye Surgeons and Physicians, the American Glaucoma Society and the California Medical Association filed in September with his agency.
"As the events at the VA hospital do concern consumers, I am formally requesting that the Board of Optometry, together with the Medical Board of California, investigate the occurrences at the Palo Alto Veterans Affairs Hospital regarding the eye care provided to veterans, including the role of optometrists and physicians in that care," Stiger wrote in a Nov. 10 letter addressed to Dr. James Ruben, president of the California Academy of Eye Surgeons and Physicians.
"To the extent permitted by existing state and federal law, I am also requesting that those boards make public the findings of the investigation," Stiger said."
By Jessica Bernstein-Wax
Daily News Staff Writer
Posted: 11/14/2009 12:04:18 AM PST
Updated: 11/14/2009 12:04:19 AM PST
"The state consumer affairs department has formally requested an investigation into the VA Palo Alto Health Care System, where 23 glaucoma patients experienced significant vision loss while receiving treatment.
California Department of Consumer Affairs Director Brian Stiger made the request in response to an administrative petition the California Academy of Eye Surgeons and Physicians, the American Glaucoma Society and the California Medical Association filed in September with his agency.
"As the events at the VA hospital do concern consumers, I am formally requesting that the Board of Optometry, together with the Medical Board of California, investigate the occurrences at the Palo Alto Veterans Affairs Hospital regarding the eye care provided to veterans, including the role of optometrists and physicians in that care," Stiger wrote in a Nov. 10 letter addressed to Dr. James Ruben, president of the California Academy of Eye Surgeons and Physicians.
"To the extent permitted by existing state and federal law, I am also requesting that those boards make public the findings of the investigation," Stiger said."
GI Bill Backlog Not Really Moving
According to the article the VA has processed just 263 GI Bill claims last week, the backlog still stands at 64,452 claims.
Full Article at: The Checks Aren't in the Mail
By Bob Brewin 11/16/09 05:02 pm ET
"Last week, when we celebrated Veterans Day, I heard from student veterans at Boston College, George Mason University and George Washington University that they had not yet received their post-9/11 GI bill stipend checks from the Veterans Affairs Department.
No stipend checks means no cash for rent or food, these student vets told me, though George Washington deserves credit for making loans to its student veterans left penniless. But one wonders how long GW will continue to act as a bank.
These anecdotal reports are backed up by VA statistics. The Nov. 16 Monday Morning Workload Report from the Veterans Benefit Administration shows that VBA had 64,452 post-9/11 GI bill claims pending, down only 263 claims, or 0.4 percent, from last week's 64,715 claims."
Full Article at: The Checks Aren't in the Mail
By Bob Brewin 11/16/09 05:02 pm ET
"Last week, when we celebrated Veterans Day, I heard from student veterans at Boston College, George Mason University and George Washington University that they had not yet received their post-9/11 GI bill stipend checks from the Veterans Affairs Department.
No stipend checks means no cash for rent or food, these student vets told me, though George Washington deserves credit for making loans to its student veterans left penniless. But one wonders how long GW will continue to act as a bank.
These anecdotal reports are backed up by VA statistics. The Nov. 16 Monday Morning Workload Report from the Veterans Benefit Administration shows that VBA had 64,452 post-9/11 GI bill claims pending, down only 263 claims, or 0.4 percent, from last week's 64,715 claims."
Report on VA Surgical Mistakes
Medical errors are a fact of life, even though we wish they were not.
I think the quote about accuracy in reporting these errors is one that needs to be taken into account.
"The concern about the nonreporting of adverse surgical events was echoed in an accompanying editorial by George C. Velmahos, MD, PhD, of Massachusetts General Hospital in Boston."
Full Article at: Surgical Mistakes Continue Despite VA Initiative
By Nancy Walsh,
Published: November 16, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.
"Despite a concerted effort to reduce them, surgical mistakes, particularly errors in communication, continue to occur in the operating room and elsewhere in hospitals, a Veterans Health Administration study found.
A total of 342 events were reported to a national database between January 2001 and June 2006, 212 of which were actual adverse events and 130 of which were close calls, according to Julia Neily, RN, of the Department of Veterans Affairs in White River Junction, Vt.
A total of 108 (50.9%) of the adverse events occurred in the operating room and 104 (49.1%) occurred in other locations such as procedure rooms and radiology suites, the researchers reported in the November Archives of Surgery.
"Incorrect surgical procedures can be devastating," and an estimated five to ten of these occur daily in the U.S., the researchers wrote.
In January 2003 the Veterans Health Administration began implementing protocols to ensure correct surgical procedures in its 153 major centers. It focused first on operating room errors and then expanded the effort to nonoperating room events in 2004 in a directive known as the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.
To evaluate the initiative, Neily and colleagues searched the administration's patient safety database for events that occurred during a 5.5 year period, and found that ophthalmology and invasive radiology had the most reports, with 45 each (21.2%).
The most common type of event involved a communication error (21%), such as mistakes in informed consent or in the dissemination of important information among staff.
Another common type of event related to "time-out" errors (17.6%), which occur when the surgical team is supposed to verify the correct patient, procedure, site, and implants (if applicable) before proceeding with the operation.
The researchers also calculated adverse event rates, reporting that there were 1.8 adverse events per 10,000 cases in ophthalmology and 1.2 per 10,000 cases in orthopedics. In both specialties the most common error was placement of the wrong implant (48.9% and 46.2%, respectively)."
"The researchers emphasized the need for communicating more clearly and earlier when preparing for surgical and invasive procedures, and suggested incorporating the patient into the preoperative briefing to aid in communication.
"We need to work proactively to prevent incorrect surgical procedures; waiting until moments before "take-off" (such as during the final time-out) may, at times, be too late to correct the problem," they wrote."
"The concern about the nonreporting of adverse surgical events was echoed in an accompanying editorial by George C. Velmahos, MD, PhD, of Massachusetts General Hospital in Boston.
"We . . . rely in great part on honesty and personal values for the candid reporting of many adverse events," he wrote.
"It is hard to imagine that errors never occur in some specialties and routinely happen in others. It is possible that honesty is exposed and penalized; an attitude of convenient forgetfulness is not," Velmahos wrote.
For example, the frequency of reported events in ophthalmology in this study may reflect a quality assurance-attentive department head.
Standardized systems that can reliably capture all adverse events are needed to minimize the need to rely on human nature, which "we would all agree . . . is rather imperfect," he cautioned."
This work was supported by the Department of Veterans Affairs.
Primary source: Archives of Surgery
Source reference:
Neily J, et al "Incorrect surgical procedures within and outside of the operating room" Arch Surg 2009; 144: 1028-34.
I think the quote about accuracy in reporting these errors is one that needs to be taken into account.
"The concern about the nonreporting of adverse surgical events was echoed in an accompanying editorial by George C. Velmahos, MD, PhD, of Massachusetts General Hospital in Boston."
Full Article at: Surgical Mistakes Continue Despite VA Initiative
By Nancy Walsh,
Published: November 16, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.
"Despite a concerted effort to reduce them, surgical mistakes, particularly errors in communication, continue to occur in the operating room and elsewhere in hospitals, a Veterans Health Administration study found.
A total of 342 events were reported to a national database between January 2001 and June 2006, 212 of which were actual adverse events and 130 of which were close calls, according to Julia Neily, RN, of the Department of Veterans Affairs in White River Junction, Vt.
A total of 108 (50.9%) of the adverse events occurred in the operating room and 104 (49.1%) occurred in other locations such as procedure rooms and radiology suites, the researchers reported in the November Archives of Surgery.
"Incorrect surgical procedures can be devastating," and an estimated five to ten of these occur daily in the U.S., the researchers wrote.
In January 2003 the Veterans Health Administration began implementing protocols to ensure correct surgical procedures in its 153 major centers. It focused first on operating room errors and then expanded the effort to nonoperating room events in 2004 in a directive known as the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.
To evaluate the initiative, Neily and colleagues searched the administration's patient safety database for events that occurred during a 5.5 year period, and found that ophthalmology and invasive radiology had the most reports, with 45 each (21.2%).
The most common type of event involved a communication error (21%), such as mistakes in informed consent or in the dissemination of important information among staff.
Another common type of event related to "time-out" errors (17.6%), which occur when the surgical team is supposed to verify the correct patient, procedure, site, and implants (if applicable) before proceeding with the operation.
The researchers also calculated adverse event rates, reporting that there were 1.8 adverse events per 10,000 cases in ophthalmology and 1.2 per 10,000 cases in orthopedics. In both specialties the most common error was placement of the wrong implant (48.9% and 46.2%, respectively)."
"The researchers emphasized the need for communicating more clearly and earlier when preparing for surgical and invasive procedures, and suggested incorporating the patient into the preoperative briefing to aid in communication.
"We need to work proactively to prevent incorrect surgical procedures; waiting until moments before "take-off" (such as during the final time-out) may, at times, be too late to correct the problem," they wrote."
"The concern about the nonreporting of adverse surgical events was echoed in an accompanying editorial by George C. Velmahos, MD, PhD, of Massachusetts General Hospital in Boston.
"We . . . rely in great part on honesty and personal values for the candid reporting of many adverse events," he wrote.
"It is hard to imagine that errors never occur in some specialties and routinely happen in others. It is possible that honesty is exposed and penalized; an attitude of convenient forgetfulness is not," Velmahos wrote.
For example, the frequency of reported events in ophthalmology in this study may reflect a quality assurance-attentive department head.
Standardized systems that can reliably capture all adverse events are needed to minimize the need to rely on human nature, which "we would all agree . . . is rather imperfect," he cautioned."
This work was supported by the Department of Veterans Affairs.
Primary source: Archives of Surgery
Source reference:
Neily J, et al "Incorrect surgical procedures within and outside of the operating room" Arch Surg 2009; 144: 1028-34.
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