Problems still exist at Illinois VA Center

From NPR Radio


November 3, 2009

A new report from the inspector general in the Department of Veterans Affairs finds that the VA Medical Center in Marion, Ill., continues to be plagued by quality management and patient care problems some two years after a suspicious spike in the number of post-surgical patient deaths there.

A 2008 investigation found that at least nine patients died because of surgical mistakes and poor post-surgical care at the VA hospital in Marion, which is in southern Illinois. That report made recommendations to improve conditions at the facility.

The new report finds poor quality management oversight, inconsistencies in the way patient deaths are reported and continuing problems with ensuring patient safety — including the discovery that surgeons were performing procedures they were not authorized to handle.

Sen. Richard Durbin (D-IL) calls the findings "appalling."

"It is inexcusable that after more than two years of adjustments and reviews, Marion VA is still failing our veterans in quality of care," he says in a press release. "This cannot and must not continue."

Durbin and other members of the state's congressional delegation, including Sen. Roland Burris (D-IL), and Reps. John Shimkus (R-IL) and Jerry Costello (D-IL), sent a sharply worded letter to Veterans Affairs Secretary Eric Shinseki in which they demanded that VA management be held accountable for the problems at the Marion facility.

A suspicious spike in post-surgical patient deaths between October 2006 and August 2007 led the VA to abruptly suspend surgical operations at the Marion VA Medical Center. NPR reported the story of a Kentucky woman whose husband died suddenly after what was considered to be relatively minor surgery for gallstones.

In January 2008, the VA's inspector general found that the surgical unit in the VA Medical Center in Marion was in complete disarray, with doctors performing surgeries they weren't qualified to perform. Hospital administrators were found to respond slowly, if at all, to complaints or problems when they surfaced.

Serious quality management and care problems were found in the surgical unit's preoperative care, intraoperative care and postoperative care. The inspector general's report found that the deaths of at least nine patients were "directly attributable" to surgical mistakes and substandard care at the Marion VA hospital. More than a dozen additional patients suffered serious harm because of such mistakes, according to the inspector general's report, and as many as 10 additional patients may have died because of poor care at Marion.

One surgeon in particular, Dr. Jose Veizaga-Mendez, was found to be prone to committing surgical errors and failing to correct his mistakes. He had been hired by the VA despite surrendering his license in Massachusetts while under investigation for malpractice there.

Shinseki has agreed to meet with members of the Illinois delegation on Wednesday to discuss the ongoing problems at the Marion VA Medical Center.

Jerald Terwilliger
American Cold War Veterans, Inc.
"We Remember"