More than 500 vets died in VA hospitals because of mistakes in last 4 years

Veterans Affairs records obtained by the Washington Free Beacon reveal the startling fact that more than 500 vets have died in VA hospitals due to mistakes since 2010.

Delayed treatment for cancer patients due to a failure to diagnose the disease and a failure to screen properly for suicide are two of the more common "adverse events" discovered in the documents.

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.

Civilian hospitals are hardly perfect, but 500 dead seems like an awfully high number of deaths as the result of errors and mistakes. Missed cancer diagnoses is not unheard of in the private sector but 74 in one year?

The delayed treatment factor is a result of the scandalous way in which VA employees tried to hide the long waiting periods for treatment. They say they are now addressing the problem but as long as the VA doesn't reform its culture, vets are going to continue to pay the price for their incompetence.

Veterans Affairs records obtained by the Washington Free Beacon reveal the startling fact that more than 500 vets have died in VA hospitals due to mistakes since 2010.

Delayed treatment for cancer patients due to a failure to diagnose the disease and a failure to screen properly for suicide are two of the more common "adverse events" discovered in the documents.

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.

Civilian hospitals are hardly perfect, but 500 dead seems like an awfully high number of deaths as the result of errors and mistakes. Missed cancer diagnoses is not unheard of in the private sector but 74 in one year?

The delayed treatment factor is a result of the scandalous way in which VA employees tried to hide the long waiting periods for treatment. They say they are now addressing the problem but as long as the VA doesn't reform its culture, vets are going to continue to pay the price for their incompetence.