Reports Organized by Veterans Administration Medical Facility
Alaska VA
Alabama VA
Even the VA admits that it doesn't punish its employees when they abuse patients Veterans Administration Medical Malpractice Information
Arizona VA
Arizona VA Nurse Pleads Guilty to Stealing Pain Medication From Patients
...Department of Veterans Affairs (VA), announced today that Diane M. Limpus, of Prescott, AZ, was sentenced to 60 months' probation, 360 hours' community service and ordered to pay a fine of $2,000. Ms. Limpus previously had pleaded guilty to one felony count of obtaining the administration of a narcotic drug, and one misdemeanor count of reckless endangerment.
Merriman stated the prosecution followed a joint criminal investigation by his Western Field Office, the Prescott, AZ Area Narcotics Task Force, the Drug Enforcement Administration, and Security Service at the VA Medical Center, Prescott, AZ, into several instances wherein Demerol was diverted and replaced with saline solution. Demerol is used to mitigate pain and saline solution has no such effect on a patient. Merriman further stated that Ms. Limpus was a licensed practical nurse working in the Domiciliary at the VA Medical Center and, as such, was responsible for the administration of medication to the patients. Limpus was immediately placed on administrative leave by medical center officials and later resigned her VA employment.
Fresno, CA VA
Fresno, CA VA Physician Sentenced for Stealing 45,620 Doses of Codeine Over 3 1/2 Years From VA Medical Center
Richard J. Griffin, Inspector General, Department of Veterans Affairs (VA), announced that on June 1, 1999, Jeremy L. D’morias, MD, was sentenced in U. S. District Court, Fresno, CA, to 6 months' home confinement and 36 months' probation. D’morias was also ordered to pay a $5,000 fine and restitution in the amount of $6,387. Previously, D’morias entered a plea of guilty to one count of theft of Government property.
Griffin stated that the sentence was a result of the combined investigative effort of his Western Field Office and the Drug Enforcement Administration. D’morias, a physician at the VA Medical Center, Fresno, admitted to engaging in a scheme to divert approximately 45,620 doses of codeine for his own use over a 3-1/2 year period
VA OIG June 2, 1999
Long Beach, CA VA
While the VA claims that the VA's policy is to disclose medical malpractice and advise individuals of their rights to file malpractice claims, this is still another example of a VA simply ignoring the VA's own policies on malpractice claims. One wonders how many veterans have been subjected to malpractice, yet remain uninformed of their right to file a malpractice claim or have their pension adjusted.
Palo Alto, CA VA
While the VA claims that the VA's policy is to disclose medical malpractice and advise individuals of their rights to file malpractice claims, this is yet another example of a VA simply ignoring the VA's own policies on malpractice claims.
San Diego, CA VA
San Diego VA Fails to advise 16 veterans of their rights, in one year, to file medical malpractice claims, does not meet VA mammography standards and fails to protect patient privacy.
San Diego VA RN Makes Mistakes With 400 Doses of Medication
Anyone can make a mistake, but to make 400 errors in medication is high, even by VA standards. All of these errors were done inside of a six month period. It works out to more than two mistakes per day.
Bay Pines VAMC
More than seventy surgical procedures were canceled at this VA, because of lack of medical equipment. In some cases the procedures were cancelled after the patient had been medicated and was undergoing anesthesia. Most of these cases involve just getting the right supplies to the right doctors and are really nothing more than administrative foul ups, except to the veteran who rearranged their life to go thru an operation, only to have it canceled because the right piece of equipment was not in the operating room. There were times when "sterilized" equipment was discovered to have blood on it.
Bay Pines Dialysis Unit Criticized for Failing to Meet Patient Safety Requirements 2005
....We found that the BPVAMC Dialysis Unit has not developed sufficient internal policies and procedures and lacked an adequate organizational structure to ensure that the quality of care provided to dialysis patients meets acceptable standards.
Although BPVAMC has various procedures relating to several aspects of dialysis patient care, it does not have a comprehensive policy manual, dialysis nursing scope of practice, or standards of nephrology practice. The BPVAMC Chief Nurse, Acute Care, and the Director of Dialysis stated that the Dialysis Unit previously had a policy manual but was unable to locate it during our visit.
Bay Pines Radiology Backlog Unacceptable and Affects Patient Care According to VA OIG-2004
Radiology Service had extensive backlogs for film and image interpretations.
Once radiological examinations are completed, a radiologist must review the
films or images produced and provide a diagnostic interpretation. The time frame
within which a radiological study should be interpreted depends on the type of
examination and the urgency of the request. According to facility guidelines,
“stat” (emergency) requests require the examination to be performed and its
interpretation completed within 1 hour. “Urgent” requests require the
examination and interpretation within 2 hours. “Routine” requests require the
examination within 30 days and image interpretation within 4 days of examination
completion.
Image interpretation backlogs have been a long-standing problem at the
BPVAMC. A February 26, 2003, memorandum from the Chief, Clinical Diagnostic
Support Service (CDSS) to the Chief of Staff reported that, “As of February
26th, the CDSS Imaging section has reduced the backlog of unread exams from
3000+ to 900 over the past 2 weeks,” and that “…it is our hope that by mid March
[2003] the section will be able to perform a 48 hour or less turn around time
for all imaging exams.” However, as of February 24, 2004, there remained 1,099
unread examinations, with some routine MRI examinations dating back to December
9, 2003.
The Acting Chief, Radiology Service, reported that delays in image
interpretation were the result of management’s failure to listen to his needs
and their denial of his repeated requests for resources. In May 2001, Radiology
Service phased in various components of the Picture Archive Communication System
(PACS) program, which allows radiologists and other providers to view digital
images on computer workstations, thus obviating the need for hard copy films. By
July 2003, all radiographic images (with the exception of mammograms) were
available on and interpreted from PACS. This enhanced technology resulted in an
increase in the number images needing interpretation.
Timely interpretations are critical to quality patient care. Delayed
interpretations of radiological examinations can result in delayed diagnosis
and, for some patients, a delay in instituting potentially life-saving
treatment.
Bay Pines VA Physicians Fail to Follow Up on Lung Cancer Cases
There Were Long Delays in Diagnosing Lung Cancer
We reviewed 10 patient medical records that were referred to us to assess
the length of time between the first radiological evidence of suspicious lung
lesions and definitive diagnosis. In six of these cases, the time elapsed from
first detection of a lesion on chest x-ray (CXR) to tissue diagnosis ranged from
49 days to 126 days (mean 82 days). In 2 of the remaining 4 cases, a clinical
decision by a physician to monitor the abnormality with serial CT scans was
made. In the third of the remaining 4 cases, no physician followed up on the
abnormal CXR. In the fourth case, appropriate work-up was scheduled, but the
patient did not keep numerous appointments for further evaluation. The clinical
presentation and ensuing events for 2 of these 10 cases are detailed below:
• On August 13, 2003, the patient had a CXR that revealed a patchy density in
the left upper lung region that suggested the presence of either an inflammatory
process or a cancer (or both). The radiologist indicated that this CXR was,
“abnormal, needs attention.” On October 23, 2003, the patient had a chest CT
scan that was interpreted as showing a lung lesion consistent with malignancy.
On November 25, 2003, he was seen by a pulmonologist who scheduled a chest CT
scan with biopsy for December 24, 2003. However, on December 13, 2003, before
that biopsy was performed, the patient presented to the medical center’s
emergency room with a fever, and was admitted to the medical center whereupon a
new CXR showed that the lung mass had increased to five times its previous size.
On December 17, 2003, he had a chest CT with biopsy that was positive for
non-small cell lung cancer. The total elapsed time from the initial suspicious
CXR to a definitive diagnosis of non-small cell lung cancer was 126 days...
Florida VA Doctor Charged with Fondling Patients at Bay Pines VAMC
...Dr. Nicholas Valenti was charged by the Office of the State
Attorney, Sixth Judicial Circuit of Florida, Clearwater, FL, with a three count
information for Battery.
Atkins stated that the criminal information was a result of an investigation by
the VAOIG Southeast Field Office and the VA Police-Bay Pines, FL. Valenti, while
employed at the VA Medical Center--Bay Pines, FL, allegedly fondled multiple
patients under his care, under the auspices of conducting medical exams.
Valenti's employment with the VA Medical Center was terminated on May 27, 1999,
and now faces a maximum sentence of three years in prison. A trial date has not
yet been set.
Gainesville, FL VA
2006
...On July 28, 2004, we received a hotline complaint alleging time and attendance abuse by a part-time physician at the medical center. The allegation stated that since her appointment, she had spent less than 5 hours per week at the medical center. The part-time physician was appointed to the medical center on November 3, 2003; she held two part-time appointments, one at the medical center and the other at the affiliated medical school. The part-time physician was required to work 25 hours per week at the medical center and 35 hours per week at the VA affiliate. The part-time physician retains her part-time appointment at the affiliate, but she relinquished her position as supervisor on January 1, 2005, for a staff physician position she currently holds at the medical center. ..
No wonder patient care is not as good as it could be. Who has time to pay attention to patients when you can watch the live entertainment instead?
Miami, FL VA
VA nurse makes mistake resulting in the loss of 1800cc to a veteran who was receiving dialysis. The nurse then lied to the veteran's doctors. Veteran dies as a result of medical malpractice. Read the VA's testimony before congress
Miami Dialysis Congressional Testimony
VA Nurse Pleads Guilty to Death of Patient at Miami VA
Tampa, FL VA
2006
VA surgeons insert non sterile cranial implants into veterans at the Tampa, VA
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In a case that is truly disturbing, the VA's own experts concluded that the VA committed medical malpractice, that resulted in the death of a young veteran who survived extensive combat wounds, and then died at the Tampa VA, because he did not receive appropriate medical care.
Georgia VA
Shreveport, LA VA
South Bend, IN VA
Uncredentialed Physicians Treat Veterans at South Bend Indiana VA
Lexington, KY VA
Lexington, KY VA Part Time Doctors Fail to Show Up & Supervise Resident Doctors in Training
Even though the VA's own studies have shown that unsupervised residents were responsible for 63 medical malpractice cases against the VA from 1997-2002, the attending physicians are still not showing up at this VA to supervise the residents.
If the attending physicians are not going to show up to supervise the doctors in training, it only makes sense for the attending physicians to le the students sign of on their own work.
Shreveport, LA VA
Shreveport, LA VAMC Director of Respiratory Therapy Pleads Guilty to Extorting Kickbacks from VA Vendors.
Kenneth R. Atkins, Special Agent in Charge, Southeast Field Office, Department of Veterans Affairs (VA), Office of Inspector General (OIG) announced today that Karen G. Curry, age 43, of Bossier City, LA, pled guilty in United States District Court to one count of soliciting and receiving illegal gratuities.
Atkins stated that the plea was the result of an investigation by his office, with assistance from the VA Police and Security Service in Shreveport, LA.
Curry, Director of Respiratory Care, Overton Brooks VA Medical Center, Shreveport, LA, was previously indicted on June 23, 1999. Curry pled guilty to corruptly demanding and receiving from a VA vendor a color laptop computer for her personal use in exchange for the VA's purchase of equipment from that vendor.
Curry will resign from her position at the Overton Brooks VA Medical Center and has agreed not to seek employment with any other facility.
Curry faces a maximum penalty of two years' imprisonment, a $250,000 fine, or both. Sentencing in federal court is governed by the United States Sentencing Guidelines. Parole has been abolished in the Federal system. Curry's sentencing date is set for December 9, 1999 at 1:15 p.m.
Popular Bluff, MI
Popular Bluff, Missouri VA physician does not show up to care for patients because he was "...feeling lazy"
Introduction
The VA Office of Inspector General (OIG) received a hotline complaint concerning the time and attendance of a full-time physician. According to the allegation, a full-time physician at the John J. Pershing VA Medical Center did not always adhere to time and attendance policies from January 11, 2004, through September 21, 2005, in fulfilling his VA appointment. Specifically, the allegation was that this physician came to work late, took long lunches, and left work early....
Results
...We substantiated the allegation that the full-time physician exhibited a pattern of time and attendance abuse during his scheduled tour of duty at the VA medical center. We determined that the full-time physician requested, and received approval for, authorized absences involving:
....
Medical center officials discussed tardiness with the full-time physician on two separate occasions.
In addition to the 15 instances when the full-time physician did not request sick or annual leave, he had repeated instances of tardiness, extended lunches, and early departures.
We were unable to evaluate the full-time physician’s time and attendance practices from January 11, 2004, through August 15, 2004, because medical center officials did not document authorized absences during this period. The physician resigned from VA on September 21, 2005....
Jackson, MI
Nursing Assistant Convicted of Assault on Patient at Jackson, MI VAMC
John McDermott, Special Agent in
Charge, South Central Field Office, Department of Veterans Affairs (VA), Office
of Inspector General, announced today that Larry Styles was sentenced in United
States District Court, for the Southern District of Mississippi, in Jackson, MS,
to seventy months in prison. Styles will serve his time at a Federal
Correctional Institute.
McDermott stated that Styles' sentencing was the culmination of investigative
efforts by his New Orleans Resident Agency. Styles was convicted in a jury trial
for his assault of an elderly patient under his care at the G.V. "Sonny"
Montgomery VA Medical Center in Jackson, MS in November of 2001. Styles was
employed there as a nursing assistant.
VA OIG Sept. 16, 2002
Kansas City VA
Kansas City VA Management Ignores Rodents & Unsanitary Conditions for Years
Fact Finder 12 Investigation into the VA Hospital in Kansas City
The pictures of these conditions say volumes about the level of care that veterans receive from the VA
Omaha, NE VA
7 Out of 9 Cases Reviewed by VA OIG at Omaha VA Demonstrated Substandard Care
Lyons, NJ VA
Albuquerque, New Mexico VA
Albuquerque New Mexico VA Found to Have Unsanitary Patient Bathrooms and Lack of Hand Washing Supplies
Washing hands between patients and after you use the rest room is a standard practice, but at this VA they don't have soap in the bathrooms used by the employees. The conditions of the the patient bathrooms would be considered unacceptable by AAA if they were inspecting a motel.
December 1, 2005
VA cancer researcher convicted of lying and harming VA patients 2005
Despite having "Dr." Kornak on its staff, who was not really a doctor, and had been convicted of mail fraud in 1992, and Regularly altered veterans records so that he could use them in a research project, the VA Still Recognized VISN 2 for quality and "Providing high quality care to veterans". It really makes you wonder what is gong on at the VISNS who weren't good enough to get this award. Anyone who thought that the VA changed after Doctor Swango is simply wrong. The VA in Albany hired him, even though he'd been convicted in Pennsylvania for mail fraud, a federal offense. We have posted the docket entries from the 1992 conviction, to show just how easily this information can be obtained by anyone and point out just how lax the VA has been in checking the credentials of the physicians that it hires.
One really has to wonder how this problem managed to a occur at two different New York VA facilities?
Northport, NY VA
Northport, NY VA hires the infamous Dr. Michael Swango after was fired from the Sioux City, South Dakota VA Hospital
Dr. Swango's Activities Were So Bad We've Given Him His Own Page
Dr. Swango's mug shot from his arrest, which led to his conviction for poisoning several coworkers in Ohio. Despite this record and conviction, he was hired by two different VA hospitals.
Northport VA Hires Physician Who Was Convicted of Poisoning Coworkers
Do you think the VA would hire a doctor who had been convicted of poisoning his coworkers? Do you think a hospital would hire a doctor who'd been interviewed on national TV after he had been convicted?
Indictment of Dr. Michael Swango for Murdering Patients at Two VA Hospitals
Durham, NC VA
VA policy requires that defibrillators be checked each shift in order to make sure that they are working, but at this VA they "gun decked" the paperwork and did not check the equipment that is used to save lives. Even the VA admits that it is "malodorous."
Muscogee, OK VA
Veteran wanders off from the Muskogee Oklahoma Veterans Administration hospital and is found dead at a nearby construction site.
unfortunately, this patient went out for smoke break and just never came back. Read the VA's statement to Congress about how this veteran tragically died, because the staff didn't notice that he was missing.
Muskogee VA, Patient Wanders Off and Dies at Construction Site
Cleveland, OH VA
VA fails to diagnosis cancer in Cleveland
Butler, PA VAveteran
Probe in to Deaths At Butler PA VA Hospital Ends
While the Center for Disease control was examining deaths at the Butler, VA, its annual report stated:
From the Butler, PA VA's 2005 Annual Report
Lebanon, PA VA
Philadelphia, PA VA
Due to lack of supplies, dentists at the Philadelphia VA failed to comply with the VA's own requirements that they change surgical gowns between patients. The VA's own inspectors found mistakes in 50% of the anesthesia records that they examined .
Pittsburgh, PA VA
VA doctor suffocates veteran when a lung tube was inserted.
Memphis, TN VA
Former VA Nurse Sentenced For Distribution of Fentanyl
Amarillo, TX VA
Amarillo, Texas VA Nurse Convicted for Stealing Drugs from Patients
Amarillo, Texas VA Nurse Convicted for Stealing Pain Medication from Patients at VAMC Amarillo
...on November 12, 2003, in Federal
District Court, Lubbock, TX, Lynda Wattenbarger, RN was arraigned on charges of
theft of pharmaceutical drugs, in which she entered a plea of guilty. She was
immediately sentenced to serve 3 years probation. As per the plea agreement,
Wattenbarger will be required to voluntarily surrender her nursing license for
the period of probation and participate in a drug rehabilitation program.
McDermott stated that the charges and resulting sentencing were the culmination
of investigative efforts by his Houston Resident Agency and the VA Police at the
VA Medical Center, Amarillo, TX. The information disclosed that Wattenbarger,
formerly employed as a ward registered nurse, was intercepting hydrocodone for
her own use for at least one year. These drugs had been prescribed to local
veterans seeking treatment at the VA Medical Center in Amarillo, TX. Complaints
from veteran patents about missing prescriptions prompted the investigation
OIG Nov 12, 2003
Austin, TX VA
l
VA Physician Convicted of Sexually Assaulting Patients at Austin VAMC
John McDermott,
Special Agent in Charge, Department of Veterans Affairs, Office of Inspector
General (VA OIG), announced today that in the 299th Judicial District Court of
Travis County, TX, Dr. Gregory S. Vagshenian was convicted of assaulting three
of his patients. Vagshenian was found guilty of nine counts of simple assault
and was acquitted of the greater charges of sexual assault by a mental health
services provider. Judge Jon Wisser announced the guilty verdict and will
sentence Vagshenian on March 22, 2004.
McDermott stated the conviction resulted from a joint investigation conducted by
VA OIG Special Agents and Healthcare Inspectors; the VA Temple Police; and other
State and Local Law Enforcement Officers. VA Psychiatrists also assisted in the
investigation and noted Forensic Psychiatrist Dr. Thomas Gutheil provided expert
testimony at the trial.
From April 1993 to May 2001, Dr. Vagshenian was employed as a Psychiatrist at
the VA Austin Outpatient Clinic, located in Austin. The victims testified
Vagshenian performed unwanted sexual acts on them under the guise of a routine
physical exam.
A
OIG February 19, 2004
“judged that these suits did not represent significant ongoing quality of care or liability concerns.” However, in an August 2003 e-mail, a PSB member addressing the facility’s chief of staff makes the following statement: “I presented him back to the PSB last Thursday which I chaired for you and everyone was in agreement that the candidate was risky. . . .”
...However, when endorsing the initial appointment, the VISN did request that special attention be given to assessing the surgeon’s skills during the proctoring period established by the PSB. Operative reports for the first 3 months of his appointment (October–December 2003) do not support consistent proctoring of the physician. Of the 41 surgeries the physician performed during his first 3 months of employment, only four were proctored as required by the provision of his appointment. Ten cases were assisted by a surgeon of the same specialty who had been appointed on the same date and also required proctoring. The remaining cases had either physician assistants and/or residents assisting the surgeries, with no other physicians recorded as present.
On November 2003, a memorandum submitted by a senior physician to the Chief of Staff indicates both physicians under the proctoring provision were now able to work independently. He also recommends the physician in question be made service chief of his specialty.
Big Spring, TX VA
Big Spring, Texas VA Pharmacist Convicted of Drug Diversion
Dallas, TX VA
Dallas VA Nurse Convicted of Stealing Narcotics from Dallas VA
It really says something when a veteran who is already hospitalized at a VA hospital, has to call 911 to get medical attention from the VA medical staff.
Dallas VA Employee Convicted of Having Sex With 14 Year Old Visitor
A 33 year old VA employee was convicted of having sexual intercourse with a 14 year old visitor, at the Dallas VA.
Houston, TX VA
Houston VA Nurse Convicted of Practicing as a Physician
...Department of Veterans Affairs (VA), announced today that, on December 18, 1997, in State Court in Houston, TX, Linda Jane Weyandt was sentenced to 21 days’ incarceration, 2 years’ probation, and 100 hours of community service for practicing medicine without a license. Weyandt also was ordered to make full restitution to all patients who filed private insurance claims, to pay $1,200 in probation fees, and to pay $25 to Crime Stoppers. A jury had convicted Weyandt on December 11, 1997. Griffin stated that the sentencing was the result of an investigation by his Central Field Office, the Houston Police Department, and the Harris County District Attorney’s Office. The evidence presented at the trial disclosed that from 1993 to 1997, Weyandt, a certified registered nurse anesthetist at the Houston VA Medical Center, operated a private clinic, practicing as a physician. Weyandt also has been charged with felony theft based upon her abuse of sick leave and absence from VA while operating her private clinic. A trial on this charge is scheduled for early 1998. Harris County Assistant Criminal District Attorney Casey O’Brien prosecuted the case.VA OIG Dec. 18, 1997
VA Physician Deported for Using VA Computer to Watch Child Porn at Houston, Texas VA
Some Houston veterans are probably wondering what their doctor was doing when he was too busy to check in on them.
Houston VA Pharmacist Sentenced for Drug Theft
San Antonio, TX VA
San Antonio Texas hires surgeon that it considers to be a "risky" candidate, doesn't subject the surgeon to the required peer review or supervision, and then promotes the surgeon.
Healthcare Inspection
Credentialing and Privileging Irregularities at the
South Texas Veterans Health Care System
San Antonio, Texas
Report No.
06-00703-147 May 22, 2006 VA Office of Inspector General Washington, DC 20420Background
The OIG Hotline Division received the above allegations from a former patient who wishes to remain anonymous. The complainant underwent surgery by the named physician in the private sector in 2001.
The complainant alleged the physician in question provided negligent medical care in the private sector prior to his employment with the Department of Veterans Affairs, resulting in over 300 malpractice claims against him. The complainant further alleged the physician had a poor bedside manner when he cared for the complainant. Finally, the complainant questioned how the VA could hire a physician with this malpractice history, indirectly alleging C&P irregularities. While we cannot address the allegations resulting from events which occurred in the private sector, this report does evaluate both the physician’s quality of care and bedside manner since his employment with the VA. We conducted a review of the physician’s malpractice claim history and application of VA’s C&P process to this physician hire.
Issue 1: Alleged Malpractice Claim History and Credentialing and Privileging Irregularities
We could not substantiate the allegation of 300 malpractice claims in the private sector, but did substantiate certain C&P irregularities related to determining the physician’s malpractice claims history. The complainant alleged the physician in question had over 300 malpractice claims filed against him prior to his appointment with the VA. The physician’s C&P file contained evidence of a total of eleven malpractice claims, three of which were reported to the NPDB. Of the remaining eight claims, five were dismissed and three were pending at the time of this review. Two of the three pending claims were filed after the physician received an initial appointment to the facility, but prior to the reappointment of the physician in August 2005. Our inspection revealed an additional claim filed in May 2005, during the term of the physician’s VA employment, against a mid-level provider as an agent of the physician in question. Therefore, we found evidence of a total of 12 malpractice claims.
The NPDB, a database containing malpractice actions resulting in a settlement or judgment against a practitioner, is "intended to augment, not replace, traditional forms of credentials review."1 VHA Handbook 1100.19, the handbook describing VA’s policies pertaining to C&P, requires primary source verification of information contained within the NPDB. VHA Handbook 1100.19 requires that the C&P file contain (1) a statement by the practitioner explaining any malpractice claims, (2) evidence that the facility evaluated the facts regarding resolution of the malpractice case(s), and (3) a "statement of adjudication by an insurance company, court of jurisdiction or statement of claim status from the attorney."2
Practitioner Explanatory Statements
The C&P file contains explanatory statements from the physician regarding the eight malpractice claims filed prior to his initial C&P application. We found no deficiencies in the submission of explanatory statements by the practitioner during the initial C&P process.
Two years after the physician’s employment with the VA began, he submitted an application for renewal of privileges (reappointment) as required by VHA Handbook
1
National Practioner Databank, "About the Databanks" www.npdb-hipdb.com.2
VHA Handbook 1100.19, 5.k.(3).VA Office of Inspector General 3
Facility and VISN Evaluation of Malpractice Cases
The C&P file contains evidence that the Professional Standards Board (PSB) reviewed the malpractice claims identified through NPDB and sought the opinion of a regional risk management official and VA Central Office (VACO). The VACO C&P Director recommended consultation with the VISN Director. A July 2003 memorandum from the facility Chief of Staff to the VISN Chief Medical Officer presented a brief synopsis of the three cases found in NPDB, adding that the facility reviewing personnel "judged that these suits did not represent significant ongoing quality of care or liability concerns." However, in an August 2003 e-mail, a PSB member addressing the facility’s chief of staff makes the following statement: "I presented him back to the PSB last Thursday which I chaired for you and everyone was in agreement that the candidate was risky. . .
…
However, when endorsing the initial appointment, the VISN did request that special attention be given to assessing the surgeon’s skills during the proctoring period established by the PSB. Operative reports for the first 3 months of his appointment (October–December 2003) do not support consistent proctoring of the physician. Of the 41 surgeries the physician performed during his first 3 months of employment, only four were proctored as required by the provision of his appointment. Ten cases were assisted by a surgeon of the same specialty who had been appointed on the same date and also required proctoring. The remaining cases had either physician assistants and/or residents assisting the surgeries, with no other physicians recorded as present.On November 2003, a memorandum submitted by a senior physician to the Chief of Staff indicates both physicians under the proctoring provision were now able to work independently. He also recommends the physician in question be made service chief of his specialty…
Reno, NV VA
Salt Lake City, UT VA
Despite having the best technology available, the VA still manages to make a serious medication error for 1 out of every 4 hospitalized patients.937 patients admitted to the Salt Lake City, VA hospital during a 20-week period in 2000. They found 483 significant adverse drug events; 25 percent of the patients hospitalized had at least one.
Puget Sound, WA VA
While the VA claims that the VA's policy is to disclose medical malpractice and advise individuals of their rights to file malpractice claims, this is another example of a VA simply ignoring the VA's own policies on malpractice claims.\
Seattle VA Nurse Pleads Guilty to Stealing Drugs from the VA
James N. Konzek, 35,
of Kent, WA, was sentenced in U.S. District Court to 4 years of probation, $4169
in restitution, and a $25 court assessment fee. Konzek had previously pled
guilty to possession of a controlled substance.
Carver stated that the charge stemmed from an investigation conducted by his
Seattle Resident Agency. The investigation disclosed that Konzek, a former VA
Licensed Practical Nurse (LPN) employed at the VA Puget Sound Health Care System
in Seattle, WA, had repeatedly removed controlled substances, including
Oxycodone, from the hospital’s supply for personal use.
VA OIG October 20, 2003
VA Psychologist Convicted of Perjury for Covering Up Sexual Relationship with VA Patient
This page was last updated on 10/05/2007 12:59 PM
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In the event that you have a Veterans Administration medical malpractice claim, you should immediately seek representation from an attorney who is experienced with litigating medical malpractice cases against the Veterans Administration or the VA.
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