VA Death Report Methods Assailed : Quality of Local Hospital Care Not Monitored, Study Finds

Veterans Administration hospitals have failed to report hundreds of unexpected deaths to VA headquarters here, including the case of a patient who was transferred 300 miles in a taxi and found dead at the end of the ride, the General Accounting Office said Wednesday in a strongly critical report.

The failure to check the quality of local hospital care is “intolerable,” said Sen. Alan Cranston (D-Calif.), who promised an aggressive effort to force the VA to investigate “unexpected deaths, patient abuse and surgical complications.”

However, “we don’t want to needlessly alarm veterans and their families,” Cranston, chairman of the Veterans’ Affairs Committee, told a news conference.

Quality of Care Doubted

Cranston and Sen. Frank H. Murkowski (R-Alaska), the committee’s ranking Republican, stopped short of accusing VA physicians of medical malpractice and improper procedures. Instead, they said, the report shows that the VA cannot be assured of the quality of care in its medical centers because its headquarters does not know what is happening in local hospitals.

“Top priority must be given to matters bearing directly on life-and-death situations in VA hospitals,” Murkowski said.

The VA’s medical center in West Los Angeles was one of nine installations where GAO investigators checked 138 cases of men who had died within a day of admission. The nine hospitals reported only 19 of these cases to Washington as unexpected deaths but should have listed 112 deaths in that category, the GAO found.

These reports are required under the VA’s patient injury control system, which directs medical centers to investigate any unusual incident that “would not be considered a natural consequence of a patient’s disease process or illness.”

Reportable Incidents

This includes unexpected deaths, such as deaths within 24 hours of hospital admission, or deaths under anesthesia; surgical complications; errors in transfusions or medications; patient abuse or neglect, and suicides, homicides and falls.

“I don’t think we have the feeling the quality of care is any better or worse than provided in other hospitals in the U.S.,” said Richard L. Fogel, assistant comptroller general, who directed preparation of the report, entitled: “VA’s Patient Injury Program Not Effective.” Fogel said the report, in effect, asks: “Is the hospital really on top of how physicians in that hospital are practicing medicine?”

“I feel the quality of care we provide and how we monitor it is equal to, and exceeds, community standards,” said Dr. Earl Gordon, chief of staff at the VA medical center in West Los Angeles, who reviews personally all the deaths that occur within 24 hours of admission.

Most of the deaths are due to terminal cancer, stroke or heart attacks, and nothing would be gained by immediate reporting of such cases to Washington headquarters, said Gordon, who is also a professor of surgery at UCLA.

‘One of Many Factors’

“Reporting of incidents is only one of many factors the VA considers in monitoring the quality of care,” he said. GAO personnel visiting the center “commended us on the quality of the incident reports and the investigations we carried out,” Dr. Gordon said.

The GAO report “deals with procedures, not the quality of care,” VA spokeswoman Donna St. John said Wednesday. “We believe VA health care is of good quality,” she said.

The VA will “reinforce” to all hospital personnel the “importance of incident reporting as a means to assure that VA provides quality health care and that federal regulations must be followed,” VA Director Thomas Turnage said in an appendix to the GAO report.

The VA hospital system, along with thousands of other public and private medical institutions, has established a reporting system aimed at reducing risk to patients.

VA medical centers recorded more than 85,000 incidents during the 1985 fiscal year, the GAO said, but “more serious incidents, such as surgical complications or unexpected deaths, generally were not reported.”

Question 613 Cases

The GAO investigators picked 714 patient cases for review and found that 613 of them, or 86%, “included unreported incidents such as surgical complications and unexpected deaths.”

Nurses were reluctant to report incidents, and, because incident reports are not confidential, there was fear of litigation, the GAO said. The federal government, rather than individual physicians, would be the target of any VA malpractice suits.

The GAO found disturbing incidents but did not identify the hospitals or doctors involved.

Murkowski mentioned the case of a cancer patient transferred by taxi 300 miles. “When the door was opened, he was dead,” the senator said. “No autopsy was performed.”

At another VA center, 8 of 13 patients undergoing cardiac surgery died during or immediately after the operation. “Center staff did not take corrective action until over a year after they had become aware of a potential problem in the surgical unit,” the GAO report said.

Cases Traced to Surgeon

In another case, the GAO discovered that a surgeon had five patients who died during operations and 28 who suffered complications.

Because the deaths were not reported to Washington as unexpected, no rapid inquiry was made. Not until a year later did the medical center begin more frequent blood testing after surgery, closer monitoring for infections and closer supervision of the particular surgeon.

“Some deaths and complications might have been avoided” had the incidents been properly reported to Washington headquarters and corrective action taken sooner, the GAO said.