Becker's Clinical Quality & Infection Control

6 INFECTION CONTROL & PATIENT SAFETY OIG: DC VA hospital had 375+ patient safety incidents in 2 years By Alyssa Rege A n investigation by the U.S. Office of Inspector General found U.S. Department of Veterans Affairs officials at nearly every level knew of sterilization issues and equipment problems at the Washington DC VA Medical Center, but were either unwilling or unable to fix those issues, putting patients at risk, according to USA Today. e OIG's report, released March 7, found investigators at multiple levels had been aware of issues at the VA hospital since 2013, but failed to remedy them. In interviews with top hospital officials, leaders "frequently abrogated individual responsibility and deflected blame to others. Despite the many warnings and ongoing indicators of serious problems, leaders failed to engage in meaningful interventions of effective remediation," according to the OIG report. Here are eight takeaways from the report. 1. e OIG began investigating the D.C. hospital aer the agency reportedly received an anonymous tip in March 2017 about supply and financial mismanagement. Following the completion of the initial probe, the investigation expanded to include 40-plus investigators comprising auditors, healthcare specialists and law enforcement, according to the report. 2. In a review of 124 patient records, investigators discovered issues with medical supplies or equipment in 74 cases between 2014 and 2017. In one instance, hospital officials canceled a surgery aer the patient was already anesthetized because a retractor had not been sterilized and was unavailable for use. 3. e D.C. hospital reportedly experienced more than 375 patient safety incidents between 2014 and 2016 due to supply issues. However, nearly half of them were not reported to the VA. Of the ones reported in the hospital's system, officials' notes did not document the severity of the incidents, according to the report. 4. Investigators seized more than 1,300 boxes of unsecured patient records from two warehouses, a trash dumpster and the hospital's basement in April 2017. Roughly 81 percent of those records contained confidential patient information, including medical scans and records dating back to the 1970s. 5. Investigators also discovered more than 500,000 items in an off-site warehouse, including $800,000 worth of refrigerators, $25,000 worth of blood pressure cuffs, two forklis worth $44,000 the hospital purchased in 2013 and 185 unusable hospital beds. 6. Between 2013 and 2017, local, regional and national VA officials reportedly received at least 10 formal complaints of supply and equipment issues, which as of last year, had not been addressed. However, in response to the OIG's report, VA officials said the agency has purchased more than $3 million worth of surgical instruments, instituted a reliable inventory system, and is working to improve safety guidelines and accountability issues, USA Today reported. 7. e OIG investigation did not find evidence former VA Secretary David Shulkin, MD, or his top officials had been aware of issues at the D.C. hospital. 8. Following the release of the OIG's report, Dr. Shulkin announced an overhaul of senior leadership during a news conference at the D.C. VA hospital March 7, according to e Washington Post. Dr. Shulkin said one senior regional official was reassigned, while two others retired. He also appointed 24 new facility directors last year to improve issues at low-performing hospitals, the report stated. "It is time for this organization to do business differently," Dr. Shulkin said. "ese are urgent issues, and many of these issues are unacceptable." n CMS cites Baltimore hospital for patient safety violations: 5 things to know By Ayla Ellison C MS cited Baltimore-based University of Maryland Medical Center Mid- town for violating several patient safety and patient rights regulations related to an incident in January, according to The Baltimore Sun. Here are five things to know. 1. In January, a UMMC Midtown patient was discharged from the hospital wearing a hospital gown. The patient, who has only been identified as Rebec- ca, was found outside the facility by a local psychotherapist, Imamu Baraka. He posted a video to Facebook, noting it was only 30 degrees when hospital security guards left Rebecca outside. He called an ambulance and Rebecca was taken back to the hospital's emergency department. 2. Rebecca initially arrived at the hospital for treatment for a head wound she sus- tained when she fell off of a motor bike. After receiving treatment, Rebecca report- edly became resistant when she was being discharged. UMMC Midtown nurses asked hospital security to help, and Rebecca was removed from the hospital. 3. A CMS investigation found several deficiencies related to the incident. CMS determined UMMC Midtown enacted barriers to patients receiving emergency care, failed to discharge a patient in a safe manner, failed to protect a patient's right to be free from all forms of abuse or harassment, and violated the pa- tient's right to receive care in a safe setting, according to The Baltimore Sun. 4. CMS also determined the hospital's staff failed to note that the patient returned to the ED within a couple of hours, which resulted in Rebecca not being recorded in the hospital's log. 5. UMMC has put a corrective action plan into place in response to the viola- tions, according to the report. n

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