The Department of Veterans Affairs’ top health official on Monday told a House committee hearing into “preventable deaths” at VA medical facilities that the incidents represented “serious but not systemic” problems for the department.
The hearing, held in Pittsburgh at the Allegheny County Courthouse, featured testimony from family members and veterans who had troubling and in some cases tragic interactions with VA medical facilities in Pittsburgh, Atlanta, Buffalo, Dallas, and Jackson, Miss.
“The patient care issues the committee has raised are serious, but not systemic,” Robert A. Petzel, VA’s secretary for health, told the House Committee on Veterans’ Affairs, which held the hearing. The hearing was titled, “A Matter of Life and Death: Examining Preventable Deaths, Patient Safety Issues and Bonuses for VA Execs Who Oversaw Them.”
Rep. Jeff Miller (R-Fla.), chairman of the committee, said that VA inspector general reports “have linked a number of these incidents to widespread mismanagement . . . the department has consistently given executives who presided over these events glowing performance reviews and cash bonuses.”
In Pittsburgh, where Legionnaires’ disease is blamed for five veterans’ death, “VA officials knew they had a Legionnaires’ disease outbreak on their hands, but they kept it secret for more than a year,” Miller said.
In Atlanta, IG reports blamed mismanagement for the overdose of one patient and the suicides of two others.In Buffalo, at least 18 veterans tested positive for hepatitis after it was discovered that the medical center had been reusing disposable insulin pins.
The medical centers in Jackson and Dallas are the subject of numerous allegations of poor patient care, Miller said.
Petzel provided the committee with details on disciplinary actions taken in connection with the events, but did not discuss them publicly. “When adverse events do occur, there are many ways to hold people accountable — when it is appropriate to do so,” he said.
Petzel said the VA has taken steps to avoid repeating problems that have surfaced in connection to the incidents, including the spread of Legionnaires at the Pittsburgh medical center.
“Lessons learned from Pittsburgh, and they are extensive, are now being used to ensure water safety at all VA medical centers throughout the nation,” Petzel said. The Buffalo incident has “triggered a national change in how our system manages the use of insulin pens,” he added.
Addressing families present at the hearing, Petzel added, “I am saddened by the stories of loss that I have heard from the families and I offer my sincerest condolences to the families here today.”