Trove of VA reports reveals research misconduct, medical malpractice

va logoLast week, the Veteran Affairs Office of Inspector General released eight years of reports investigating allegations of nefarious behavior at VA hospitals and institutions around the country, ranging from mistreating a patient in Florida, misspending grant money in New York, and conducting unauthorized research in Iowa.

In one report, a researcher with a foreign medical degree was misrepresenting himself to patients as a physician, and was “inappropriately” allowed inside an operating room during a spinal cord injury study. In another, researchers in Buffalo, New York, burned through a grant on traumatic brain injury by sprucing up their break room and buying a new ice machine.

In the past, such reports would not be published, and would only be obtainable through freedom of information requests. That’s because the Office of Inspector General only publishes reports of healthcare inspections that result in findings of wrongdoing or problems at VA institutions.

However, in cases where the Office cannot substantiate allegations, where the allegations become the subject of a lawsuit, or where problems have already been acknowledged and addressed by the institution, the investigation is “administratively closed” and the report is essentially buried. That changed this week due toscrutiny by Congress over the last year combined with a freedom of information filing. Beginning on April 21st, redacted reports dating back to 2006 were rolled out on the OIG website.

One of the most intriguing misconduct reports details a physician, code-named “Dr. A”, who was confirmed to have conducted “unauthorized research” at a VA Hospital in Des Moines, Iowa and presented his findings at an international conference. Basically, Dr. A was taking extra images on a medical imaging machine and was caught when a patient log went missing in 2007. Here’s what the report says:

Documents and interviews from Dr. A and nuclear medicine staff support that he requested an extra film image of patients at the first 5-minute period . . . According to facility patient logs, there were 41 patients who were subjects of the additional 5-minute radiology image.

Images are typically taken at 60 minutes. The researcher’s hypothesis, according to the report, was the extra 5-minute image would help diagnose a condition, the name of which was redacted from the report. Evidently, the Department of Health and Human Services blocked him from publishing a book chapter that might have included the findings. He was later convicted and sentenced to fraud, and was on the Department of Health and Human Services Exclusions List at the time of the 2009 report. The facility ended its research program in 2007.

The VA OIG closed the case:

Because the facility had notified appropriate research oversight when they were aware of the situation and undertaken corrective actions to prevent similar occurrences, we recommend administrative closure.

We were unable to find a more complete record of the case.

Besides research misconduct, the reports consist of a grab bag of alleged medical and administrative errors in the VA system. In one case, a 79-year old man with diabetes and partial amputation broke his leg (presumably the other one) while he was getting treated at the VA Medical Center in Bay Pines, Florida. The hospital lost his prosthetic for 10 days and dropped him off alone in his front yard without notifying his family.

Not all the reports were so grim. For instance, have you heard the one about the Ear, Nose, and Throat surgeon who couldn’t manage to keep his mouth shut? After a surgeon in New Orleans was singled out for “excessive surgical times,” his supervisor had a pretty good idea what the problem was:

The Chief of Surgery believed that the surgeon’s slowness was due in part to excessive talking during surgery. The chief counseled the surgeon about staying on task during surgery and reducing unnecessary conversation.

Another one just seemed like child’s play. No really. At the VA Hospital in Albuquerque, New Mexico, an employee brought a nine-year old child into the operating suite for a fun-filled day of watching a man have part of his prostate removed. According to the report:

The child was removed from the OR after a physician assistant saw her on an elevated riser peering over the drapes leaning onto the sterile field without protective eyewear.

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