Veteran goes in for surgery: VA mistakenly embeds 10-inches of plastic packaging in a critical artery


The US Department of Veterans Affairs (VA) provides patient care and federal benefits to veterans. Many Veterans have complained about the quality and expediency of the care they receive at the facilities. One case, reported by USA TODAY on Thursday, boggles the mind: a veteran with diabetes and poor circulation ended up with a foreign body implanted in him by medical staff at the Memphis VA Medical Center.

The man reportedly went to the VA center last year for a scan and possible repair of blood vessels in his right leg. Somehow, 10-inches of plastic packaging was mistakenly embedded in a critical artery, which doctors didn’t discover until the he went back three weeks later to have the leg amputated.

According to the report, the plastic piece is a shipping product used by manufacturers to protect catheters while they’re in transit. After the amputation procedure, they found 3-inches in his remaining leg and 7-inches in the amputated limb.

Apparently, the man’s case is only one of a number of noted patient safety issues at the Memphis hospital, which was called a “house of horrors” by one former employee. The USA TODAY Network has chronicled the allegations “in a trove of internal documents” which “provide a revealing glimpse of one of the worst of 168 VA hospitals in the country.”

USA TODAY reports:

“The hospital is one of only four on which the VA’s top health official, acting Under Secretary for Health Poonam Alaigh, requested weekly briefings, according to the documents.

“The Memphis VA scores only one out of five stars in the agency’s quality-of-care rankings and the documents show reports of threats to patient safety at the hospital soared to more than 1,000 last year, up from 700 the year before.”

Serious incidents investigated in 2016 include:

  • the medical center mishandled a tissue sample resulting in a repeat biopsy
  • a provider perforated a patient’s colon during a colonoscopy
  • a patient with abdominal pain and blood in his urine waited two hours in the emergency room before leaving for another local hospital where the patient “was deemed urgent and seen immediately”

VA statistics indicate the Memphis VA is one of the worst in the country for patient safety, inpatient outcomes, and death rates following acute care or pneumonia treatment.

USA TODAY notes additional problems with the Memphis VA, including:

  • In 2012, investigators concluded veterans had endured serious treatment delays at the hospital, with an overcrowded emergency department, patients were left on stretchers in hallways for as long as 14 hours and others who left without ever being seen.
  • In 2013, investigators found there were delays in processing “urgent laboratory tests,” and that patients had died in the emergency room.
  • In 2013, one patient received a medication they were known to have an allergy to, another wasn’t monitored after receiving sedating medications, and a third with high blood pressure suffered a bleed in the brain after inadequate monitoring.
  • In 2014, employees reported continuing lapses, from neglected medical records to contaminated medical equipment.
  • In 2015, a video purportedly showed an empty nurses’ station in the critical spinal cord wing.
  • In 2016, VA officials ousted the hospital’s director amid “under-performance” issues
  • In 2016, OSHA, which monitors workplace safety, issued multiple citations to the hospital in for improper disposal of human tissue.

“It’s a house of horrors,” said Sean Higgins, a former logistics technician at the Memphis VA reportedly said.

USA TODAY reports that a new director took over in May. Officials have conducted a top to bottom review of the facility, according to VA Press Secretary Curt Cashour, speaking as spokesman for VA Secretary David Shulkin. Cashour says staff changes have been made in surgery, research, nursing, engineering and human resources.

Under Shulkin, who took over as secretary in February, the agency is trying to identify and vulnerabilities in the VA system.

“When we determine facilities need extra attention — such as those in Memphis and Marion, Ill. — they are receiving it,” Cashour reportedly said. “And we are not hesitating to take swift accountability actions when warranted.”

Cashour reportedly said the VA wants to “understand how these problems developed, and hold accountable those responsible.”

According to USA TODAY, the other VA hospitals reporting weekly to the VA’s top health official include :

• Marion, where significant declines in patient safety culture and reported deaths prompted an investigation earlier this year.

• Washington, D.C., where investigators found surgical shortfalls earlier this year that placed veterans in imminent danger.

• Manchester, N.H., where The Boston Globe revealed dangerous conditions in July, including a fly-infested operating room and canceled surgeries.

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