27 August, 2019 05:37

Military Times: Did VA hospital leaders ignore recalls on faulty medical equipment?

By:Leo Shane III   1 day ago
341
Staffers at a Florida-based Veterans Affairs hospital say leadership ignored a medical equipment recall for weeks — even after a patient’s life was endangered — despite repeated warnings their inaction violated health and safety norms.
But officials at the James A. Haley Veterans’ Hospital in Tampa said their week they have removed all of the faulty items without any harm to patients, dismissing concerns that proper procedures were not followed.
It’s unclear whether the dispute is isolated to the single VA medical center or indicative of larger problems with recall alerts throughout the nation’s veterans hospital system. Department of Veterans Affairs officials in Washington, D.C. referred all questions to local hospital officials.
At issue is a July 31 incident where a patient at the Tampa medical center received too much prescribed medication because of what nurses described as malfunctioning IV equipment. Tubing designed to slowly drip out fluids into the patient’s bloodstream instead allowed a rush of medication all at once. In a grievance filed with facility leadership, staff said a medical disaster was avoided only because nurses on duty quickly diagnosed and responded to the problem.
Butin a statement to Military Times, hospital leadership said that “no patient harm” occurred and praised medical personnel on staff for quickly identifying the problem. They also said an internal review found no specific equipment malfunctions but did uncover some system parts that were on recall lists.
Dennis McLain, head of the facility’s National Nurses United chapter, said the manufacturer of the IV tubing (BD, headquartered in New Jersey) issued an urgent recall of the equipment two weeks earlier, instructing hospitals to “destroy all products” found in their inventory.
“Since this issue may lead to flow inaccuracies through the pumping cycle process, this may result in an over-infusion and the potential for serious patient injury or death, depending on the type of medication that is being delivered,” the July 18 recall notice states.
In the grievance, McClain said the Tampa site continued not only overlooked that notice but also continuedto use the faulty tubing for weeks after the July 31 incident, even after the union filed its formal complaints in early August.
Leadership issued a response this week (after Military Times inquiries on the matter) stating that “after speaking with the manufacturer today to ensure compliance with the recall, staff received additional clarification on tubing products affected” and that now “all affected IV tubing found at the facility is being replaced immediately.”
Identifying the parts is difficult once it is in use, hospital officials said in their response to the union grievance, because they lack clear model numbers and identification markers once taken out of packaging.
But McClain said he is baffled it took more than a month for any action to address a known recall. Union officials have asked the department’s inspector general to look into whether proper procedures were followed.
According to VA policy, all medical equipment recalls are reviewed and posted on a centralized website for physicians and facility administrators. Officials said all of the recalls are monitored for “impact, relevance, and risks to patient care.”
McClain said several nurses who raised concerns about the ignored recall were told that shortages in IV equipment were to blame. In their response to the grievance, VA officials flatly denied that, and said appropriate inventory is available.
They promised a full inspection of all IV equipment at the facility to ensure all of the systems are working properly. Staff members remain doubtful all the recalled equipment has been removed.
“There is no excuse why we waited this whole time,” McCalin said. “They should have dealt with this earlier.”

Military.com: The VA Removed a Vet’s High-Risk Label. The Patient Died by Suicide. What Went Wrong?

26 Aug 2019
Military.com | By Richard Sisk
Again and again, teams at the Department of Veterans Affairs‘ San Diego Health Care System reached out to and helped a troubled veteran battling suicidal thoughts and substance abuse who frequently missed appointments or broke off contact.
The efforts were not enough. The veteran was found dead in July 2018; the San Diego Medical Examiner’s Office ruled the death a suicide by asphyxiation.
Prompted by charges from an anonymous caller, the VA’s Office of Inspector General (OIG) investigated the circumstances of the death and issued a report earlier this month titled: "Alleged Deficiencies in Mental Health Care Prior to a Death by Suicide at the VA San Diego Healthcare System, California."
The anonymous caller who claimed that the veteran was "turned away" by the VA could not be reached by the IG’s office to back up the accusations.
"The OIG inspection team attempted to contact the complainant by telephone, certified mail, and electronic mail; however, the complainant did not respond," the report states.
The 27-page IG report found procedural "deficits" in how the San Diego VA dealt with the veteran, but stopped short of leveling blame.
The IG’s detailed report offered penetrating insight into a case that is emblematic of the challenges faced by the VA health care system. As VA staff serve nine million veterans each year, they must contend with what officials have described as an "epidemic" of suicides among veterans.
The challenges become even more acute, the IG report shows, when the veteran misses appointments, rejects treatment plans or sporadically ignores attempts at outreach.
The investigation was conducted to assess whether the VA failed to provide mental health care to a patient who subsequently died by suicide. Ultimately, investigators did not substantiate claims that the VA failed to provide mental health care when the patient sought help, according to the report.
"The OIG found that the suicide risk assessment of the patient was adequate" and complied with the standards of the Veterans Health Administration and the San Diego system’s requirements, the report states.
Still, there were serious shortcomings. Investigators identified the move to deactivate the patient’s flag in medical records noting a high risk for suicide as a concern. The suicide prevention coordinator at the hospital removed the veteran from the high-risk list "without contacting the patient" or "consulting the patient’s treatment team," the report states.
The veteran remained off the list even after failing to show up for mental health services for more than two months.
Patients are supposed to be added to the high-risk list so VA staff members can track those veterans closely, making efforts to reach them when they miss or cancel appointments, agency guidelines state.
The IG made two recommendations for improving procedures and documentation at the San Diego VA based on a case that could serve as a valuable example for systemic improvements.
Investigations of such deaths often center on what the VA did, or didn’t do, to assist the veteran, although statistics show that about 14 of the 20 veterans who die daily by suicide never have any contact with the department.
"It seems like the VA did a lot of things correctly" based on the IG report, said Navy Reserve Cmdr. Jeremy Butler, CEO of Iraq and Afghanistan Veterans of America. "But it’s not a totally clean bill of health."
Butler called the issue of veteran suicide "a national emergency."
"We realize the VA can’t do everything," he said, but he questioned the removal of the veteran in the San Diego case from the high-risk list.
Butler said the San Diego suicide case underlined the need for the VA to engage in more outreach to veterans, either by the department itself or through local and state partners when veterans become difficult to contact.
VA Secretary Robert Wilkie has repeatedly cited curbing the veteran suicide rate as the "top clinical priority" for the system’s 170 hospitals and more than 1,100 clinics nationwide.
In March, President Donald Trump signed an executive order creating a cabinet-level task force that he pledged would "mobilize every level of American society" to address the crisis of suicides among veterans.
The death of the veteran in San Diego, and the report of the IG on the circumstances, illustrate how difficult the task will be.
Early Warning Signs
The veteran in this case, who was identified only as the "patient" due to privacy rules, was younger than 30 at the time of death.
The veteran’s gender and military branch were not disclosed, but investigators found the individual "first experienced depressive symptoms including insomnia and thoughts of suicide during high school but did not seek treatment at that time."
Just a month after joining the military in 2013, the patient met with a counselor and was "feeling really depressed," the report states, but chose not to start medication until the summer of 2014 for fear that it might interfere with training.
The patient was then prescribed two antidepressant medications and a sleep aid. The patient’s first contact with the VA came in the spring of 2017, after leaving the military.
"During that visit, the patient complained of periodic thoughts of self-harm," the report adds. "The patient asked to restart psychiatric medications, and the primary-care provider prescribed an antidepressant."
The investigation goes on to detail several contacts and visits to the VA by the patient, though it notes the veteran’s follow-up on advice or treatment suggestions was sporadic.
In the initial visit to the VA, the patient described "chronic passive suicidal ideation" and recounted an attempt while in the military. The patient ultimately stopped the attempt and called a suicide hotline, the report states.
A VA social worker drew up a risk assessment in which the patient reported researching methods of suicide on the internet. The social worker estimated the patient’s risk of suicide to be "moderate/ambivalent," but the patient did not think a safety plan would be useful and declined to complete one.
Then followed meetings with a VA psychiatrist and psychologist in which the patient would ask for changes in medication and admit to substance abuse while refusing treatment for it. The patient also met with a private psychologist under the VA’s "Choice" program for private-care options.
Rescheduled Appointments
In the summer of 2017, after the patient rescheduled appointments multiple times, the VA psychiatrist called the patient.
"The patient reported intrusive thoughts of suicide" and spoke of planning to discuss them with the VA Choice provider, but also "denied active suicidal ideation, intent, or plans," the report states.
The psychiatrist called the patient’s Choice provider less than a week later. They agreed that, although the patient did not meet criteria for inpatient psychiatric admission, the patient was at long-term elevated risk for self-harm, according to the report.
"During a follow-up psychiatric visit four days later, the patient admitted to a suicide attempt in mid-summer of 2017," the report continues.
This attempt was also stopped by the patient after about a minute, the report states.
There was more back and forth between the VA and the patient on recommendations for treatment and medication, many of which the patient ignored, according to the report.
In early 2018, the VA psychiatrist reached out to the patient following a missed appointment. The patient said that two weeks prior while at an airport, they sent a photo to a friend showing an apparent self-strangulation attempt, and then turned the phone off, the report states.
The friend contacted the patient’s family, who called airport security.
"The patient said that the police spoke with the patient upon landing but did not detain the patient," according to the report.
Three days after the phone call, it adds, the patient agreed to an intensive outpatient program referral, but declined the psychiatrist’s offers for substance abuse treatment or restarting psychiatric medication.
"After the patient missed the next appointment, the psychiatrist contacted the system emergency department social worker, who called police and requested a health and welfare check," it continues.
"During the health and welfare check, the patient expressed passive thoughts of death but did not meet criteria for inpatient admission," the report states. "The patient agreed to follow up with the outpatient providers the following week but did not."
After multiple calls to the patient without a response, the VA psychiatrist called the patient’s mother and left a voice message. The patient’s mother called back and said that she was speaking with the patient twice a week and was appreciative of staff concern, the report states.
Suicide Risk Flag Deactivated
In late winter 2017, a VA suicide prevention coordinator, or SPC, contacted the patient, who reported "decreased depression, and decreased frequency and intensity of suicidal thoughts."
"The SPC changed the patient’s suicide risk assessment to moderate/ambivalent," and after additional calls, the patient’s suicide risk flag was deactivated in late spring of 2018, the report states.
However, in the summer of 2018, the patient went to the VA emergency room with thoughts of suicide, according to the report.
The patient was evaluated by a second-year psychiatry resident, who "described the patient as ‘pleasant, engaging, and jovial at times,’ despite the patient’s self-report of feeling suicidal for the prior two days after a fight with a friend," the report states.
The patient denied symptoms consistent with major depressive disorder, investigators found, including changes in appetite, energy or concentration, but admitted having fleeting thoughts of suicide most days of the week.
"The resident offered the patient voluntary psychiatric admission for stabilization, but the patient declined," the report states. "The patient stated that the conversation with the resident had improved the patient’s mood and the patient now felt safe to return home with a roommate."
The resident decided that the patient did not meet the criteria for involuntary admission or "warrant psychiatric inpatient admission at that time," according to the report.
"The resident assessed the patient’s short-term risk of suicide as low," but "acknowledged that the patient’s long-term risk of suicide was elevated given the patient’s history of chronic suicidality and other mental health conditions," the report adds.
The staff psychiatrist at the hospital co-signed the resident’s consultation note about four hours after the patient left, the report states, and the resident added the outpatient psychiatrist, outpatient psychologist and lead suicide prevention coordinator to the note.
Several days later, the outpatient psychiatrist attempted to contact the patient by phone and left a voice message asking the patient to return to care. A psychiatry medical support assistant later attempted to phone the patient but was unsuccessful, according to the report.
The medical support assistant then sent a letter to the patient "that encouraged the patient to call to schedule an appointment and noted that there would be no further attempts to schedule an appointment," the report adds.
"The patient expired two days after the medical support assistant sent the letter," the report states. "The Deputy Medical Examiner reported the patient’s cause of death as asphyxia [suffocation] and manner of death as suicide."
In response to questions from Military.com, the IG office said that the detailed analysis of an individual case could point the way to improvements in suicide prevention.
"It is hoped that the identification of failures in a specific case will lead to lessons learned across the VA system of care," the office said in a statement.
In its response, the VA’s San Diego Health Care System thanked the IG for the "thorough review of the circumstances involving this tragic veteran suicide which occurred in July 2018," but did not refer to any "failures."
"We appreciate their confirmation that there were no deficiencies in the care of the veteran provided by our mental health providers or our emergency department, or in the supervision of the resident physician staff who also participated in the veteran’s care," Cynthia Butler, public affairs director for the San Diego VA, said in a statement.
On the subject of red flags for high-risk patients, Butler said, "We are also working with the VA Office of Mental Health and Suicide Prevention to assure that consistent processes are developed and implemented for the management of flags alerting staff to the presence of veterans who may be at higher risk for suicide."
Navy Times: Navy quietly ends climate change task force, reversing Obama initiative
By:J.D. Simkins   14 hours ago
4.4K
When he took office as secretary of defense, retired Marine Gen. Jim Mattis urged the armed forces to battle the effects of global climate change.
The order by Mattis was backed by a slew of scientific studies — including those commissioned by the Pentagon — and concerns expressed by a growing number of past and present military leaders.
“Climate change is impacting stability in areas of the world where our troops are operating today,” Mattis indicated in written testimony to the Senate Armed Services Committee in 2017.
“It is appropriate for the Combatant Commands to incorporate drivers of instability that impact the security environment in their areas into their planning.”
But the Navy quietly shut down its specialized U.S. Navy Task Force Climate Change in March, reversing an Obama-era initiative designed to prepare naval leadership for global shifts in sea levels, melting ice sheets and ocean temperatures.
Navy officials told E&E News, which initially reported the termination of the program, that the task force’s mission was one that was “no longer needed.”
But questions soon arose into whether task force’s demise could be traced to ongoing efforts by President Donald J. Trump to end to numerous federal agency climate change initiatives, reversing policies instituted by the previous administration beginning in 2009.
“I believe that there’s a change in weather, and I think it changes both ways,” Trump said in a June 2019 interview on “Good Morning Britain.”
“Don’t forget it used to be called global warming. That wasn’t working. Then it was called climate change. Now it’s actually called extreme weather, because with extreme weather, you can’t miss.”
Trump’s remarks arrived two years after he announced the United States’ withdrawal from the Paris accord to battle climate change by preventing a 2 degrees Celsius rise in global temperature above pre-industrial levels.
The president said that U.S. participation would “undermine our economy" and leave the nation "at a permanent disadvantage.”
While Trump downplayed the problem, his Pentagon quietly continued to follow a “climate change adaptation roadmap” to protect against catastrophic storms that put coastal bases at tremendous risk.
That trail had been blazed for military leaders in a 2010 report by U.S. Joint Forces Command. It was forwarded and signed by then-Gen. Mattis.
The JOE — Joint Operating Environment — assessment cautioned that climate change had become one of the top 10 trends facing military leaders, especially commanders who might be called to conduct missions in coastal zones less than 10 meters above sea level.
That’s where about one-fifth of the world’s population lives, people who are uniquely at risk for floods, tsunamis, hurricanes and other potential disasters.
“If such a catastrophe occurs within the United States itself — particularly when the nation’s economy is in a fragile state or where U.S. military bases or key civilian infrastructure are broadly affected — the damage to U.S. security could be considerable,” the report warned.
The report’s authors also looked at how rising powers such as Russia and China were seeking to exploit the potential effects of climate change on the polar regions.
“Sea ice has been shrinking dramatically in Arctic regions each summer, and in the future this could open new shipping routes across archipelagic Canada and Northern Russia that could dramatically shorten transit times between Europe and Northeast Asia," according to the 2010 report.
Nine years later, the concerns of the paper’s authors were reinforced by a similar Department of Defense report that revealed recurrent flooding, drought, desertification, wildfires and thawing permafrost threatened more than two-thirds of military installations critical to mission capability.
In the Hampton Roads region in Virginia, for example, officials saw "recurrent flooding today, and we are beginning work to address a projected sea-level rise of 1.5 feet over the next 20 to 50 years,” the 2014 road map claimed.
Naval Station Norfolk — the headquarters of the Atlantic Fleet where sea levels have risen nearly 15 inches since World War I — floods about 10 times annually, a number estimate will rise to 280 events by the year 2100, according to a report by The Union of Concerned Scientists.
In March, former Secretary of the Navy Ray Mabus wrote that climate change “is a national security threat.”
“Stronger storms will lead to increasing damage to coastal military facilities, as when Hurricane Michael caused substantial damage at Tyndall Air Force Base in Florida. Stresses on resources and agricultural changes will increase the global flow of refugees and cause cross-border instability. That, in turn, will mean greater involvement of U.S. forces around the world," Mabus warned.
But the sense of urgency that flowed through the reports between 2010 and 2019 neither buoyed the Navy’s climate change group nor sparked major reforms across the armed forces.
Retired Rear Adm. Jon White, who spearheaded Task Force Climate Change from 2012 to 2015, told E&E News that he saw “little evidence” that the research undertaken by the Navy and scientific community has even been implemented in any of the military’s environmental strategies.
“Across all of the Department of Defense, it is hard for me to see that climate change is taken as seriously as it should be,” said White, now the president of the Consortium for Ocean Leadership.
“The task force ended, in my opinion, without full incorporation of climate change considerations.”