9-13-2013

House Panel Reviews Preventable Deaths at VA

The House Veterans Affairs Committee held a field hearing recently at the Allegheny County Courthouse in Pittsburgh, Pa., to examine the emerging pattern of preventable veteran deaths and serious patient-safety issues at the Department of Veterans Affairs (VA) medical centers across the country. The Committee focused on recent events at VA medical centers in Atlanta, Pittsburgh, Dallas, Buffalo and Jackson (Miss.) and discussed the adequacy of current VA management and accountability structures.

Rep. Jeff Miller (Fla.), committee chairman, noted that the VA “has consistently given executives who preside over these events glowing performance reviews and cash bonuses,” citing an instance where the death of five Pittsburgh veterans from Legionnaires disease was kept secret for a year. The top VA official in that region received a bonus a few days after the VA Inspector General report was released indicating that the outbreak was a result of mismanagement. In addition to numerous allegations of poor patient care, the IG report also attributed a patient death by overdose and two suicides in the Atlanta facility to mismanagement and cited the reuse of disposable insulin pens as the cause of 18 veterans contracting hepatitis in Buffalo. 

Robert Petzel, VA Undersecretary of Health, told the committee that “patient care issues raised by the committee are serious, but not systematic.”  Petzel also provided the committee information outlining disciplinary actions taken in response to these events and steps VA has taken ensure these problems are avoided in the future.