Va Required To Notify Of Mistakes In Care?

[Guest morgan]

I just got this from The Charlotte Observer Web site and wanted to see if anyone else here knows if VA regulations require that patients and their families receive notification of mistakes with care? The article has no reference to a specific regulation, so I'm not sure if this is so. What say you, hadit fambly?

Cases like this are very sad:

VA's silence on death

brings grief, confusion for family

STELLA M. HOPKINS

shopkins@charlotteobserver.com

Tim Alexander picked up his dad from the Asheville VA hospital on a sunny fall Sunday for a cookout. He knew his father was dying, but that day was a good one. Don Alexander enjoyed Tim's birthday party with friends and family.

By Friday, he was dead.

For more than two years, the Alexander children wouldn't know the details about his final hours at the hospital's nursing home. Even then, they say, hospital officials misled them about what had happened.

Responses from the Department of Veterans Affairs to Observer questions about the case differ from agency documents obtained through Freedom of Information requests.

This spring, the Alexanders learned from Observer reports that their father's 2004 death followed a procedure performed by an untrained physician assistant. No one had told them that his death, at 73, was among the factors that prompted a VA investigation that year and led to admissions being suspended at the hospital's nursing home unit. They didn't know that investigators said the procedure was a mistake because Alexander's blood pressure was very low.

"I couldn't believe it," Donna Alexander said last week. "We were never given any indication that my dad's death was anything other than normal."

A VA spokeswoman said in an e-mail Friday evening that nothing the staff did contributed to or caused Alexander's death. A review by doctors determined that he received "appropriate" care, spokeswoman Karen Fedele said in the e-mail. VA documents show that the peer review was not as critical as a report by VA investigators but still found that "most experienced, competent practitioners might have managed the case differently."

Acknowledging mistakes

VA regulations require that patients and their families receive notification of mistakes with care. Alexander's case and other incidents make clear that doesn't always happen at the two main hospitals serving Charlotte-area veterans.In April, the VA told the Observer that the Alexander family "was not notified in a timely manner." On Friday, Fedele said the VA wasn't required to make any disclosure to the family.

During a congressional hearing in April, lawmakers chided Salisbury VA officials because the hospital had not shared word of care problems with seven patients. The Observer also has talked with two other families who were not told of problems that led to loved ones' deaths in Salisbury.

The VA didn't even respond promptly to a congressional request. During the April hearing, U.S. Rep. Mel Watt asked for details on the Salisbury VA cases. Last month, the Charlotte Democrat said he told the VA, "Your failure to respond is unacceptable." On Wednesday, his office said he still hadn't heard.

The VA said Friday that it had provided a response, but it didn't say when.

Medical mistakes, from faulty surgery to incorrect medications, are a leading cause of death, injury and illness nationwide. There also is a push to tell patients and their families about mistakes, any investigations and corrective steps.

Experts, including a former VA doctor, say the Alexanders' experience is egregious because they learned of problems from news reports and feel the hospital didn't provide complete information when asked.

"We found the vast majority of people would easily forgive you for making a terrible mistake if you acknowledge you made a mistake," said Dr. Steve Kraman, a VA doctor for 26 years and an early advocate of error disclosure. "You give people information that by rights belongs to them. You say what you're doing to prevent it again."

Doing otherwise destroys trust.

"You start to assume people are lying all the time," said Rosemarie Tong, head of UNC Charlotte's Center for Professional and Applied Ethics and a professor of health care ethics. "In a health care environment, if you can't trust people, it's pretty scary."

`They told me ... not to worry'

Don Alexander entered the Asheville VA in fall 2004 for hospice and nursing care as he battled heart disease.

On Oct. 25, 2004 -- the day after her brother's birthday cookout -- Donna Alexander visited their father for about 90 minutes. He sat outside in his wheelchair. The retired real estate broker and home builder had been listening to a recorded book on how to become a billionaire.

"My dad was sharp," his daughter recalled. "We had an amazing conversation."

His health problems included fluid buildup in his abdomen, which causes pain and can make breathing difficult. The fluid can be drained by making an incision and inserting a tube. He recently had this procedure, called paracentesis, at least twice. That week, on Thursday afternoon, he had a third.

Tim Alexander recalls seeing containers filling with fluid and wondering if it was safe to remove so much. His sister said she asked nurses several times why her father was so lethargic, barely opening his eyes.

"They told me what my dad was going through was perfectly normal and not to worry about it," she said.

She didn't know his blood pressure was dangerously low -- 58/34 at one point.

Reassured, she left around 8 to spend the night at her brother's house. Early the next morning, he got a call that their father had died.

"There's no question my father was on his deathbed, but ... I thought he probably had six, eight weeks, maybe 10," Tim Alexander said. "It just took a very quick turn, and now we know why."

`My dad died alone'

One month after Don Alexander died, an employee at the Asheville VA called the agency's medical investigators in Washington to warn of care problems. Investigators arrived within the week and reviewed four cases, including Alexander's and those of two men who died suffering extreme pain.On Dec. 17, the VA directed the hospital to suspend nursing home admissions, saying the staff didn't know how to care for dying patients. Some admissions didn't restart for eight months.

The Observer first wrote about the Asheville problem in March after obtaining the investigators' report through a Freedom of Information request. Patients' names were blacked out. The Observer identified Don Alexander through public records and contacted the family.

The report and other documents recently received detail Alexander's last day and investigators' conclusions.

At 3:24 p.m. on Oct. 28, 2004, a physician assistant performed the draining procedure on Alexander. His blood pressure was 63/32 at the time and fell lower by 4 p.m. VA investigators said the draining was a mistake because of Alexander's "profoundly" low blood pressure. The amount of fluid removed was unusually large, and he didn't receive replacement fluids.

By 2 a.m. the next day, nurses noted that he was bleeding, and his blood pressure remained very low. At 6:42, they wrote, he was "Trying to sit up and wanting to go to ER." Don Alexander died soon after.

"My dad died alone, and we were less than 10 minutes away," Donna Alexander said.

Investigators say the physician assistant was not trained in the procedure and was not "appropriately supervised" by a doctor. There was no follow-up with the patient by a doctor or the physician assistant. A Washington VA official has said that no one was fired "because no one was deemed incompetent and there was no malicious intent." The VA says the hospital took disciplinary action but wouldn't reveal what.

This April, Tim Alexander saw a brief mention in an Asheville paper about a man who had died at the VA hospital in 2004. The man had had a procedure to drain abdominal fluid.

He wondered: Could that man have been my father?

Grappling with the system

Alexander, a custom home builder, carried the news clipping around for a week or so. Finally, he called the Asheville VA to ask questions. They invited him for a meeting on April 18 to "express condolences and review the circumstances leading to his father's" death, VA spokeswoman Fedele said Friday.

A hospital official met Alexander when he arrived.

I guess you have figured out by now that this investigation involved your father, he recalls her saying during an elevator ride. No, he hadn't.

Two hospital officials talked with Alexander. He says he feels they misled him by describing the investigation as a routine, in-house follow-up after the death of a patient -- not a probe by VA headquarters' investigators.

Alexander, unfamiliar with the complexities of VA reporting, says officials did not make clear to him that there were two investigations. One was the routine peer review, the other an unusual visit by the VA Office of the Medical Inspector.

The inspector's office can handle most investigations from Washington using electronic records. Investigators only made on-site visits to hospitals 27 times in the past three years -- two of those within seven months to look at problems in Asheville.

Alexander says the hospital told him little about investigators' conclusions, only that they found no wrongdoing and made some staffing changes. He asked for a copy of the findings but was told he couldn't have it.

Peer review reports are protected by law. The inspector's report can be released. He said officials told him they would mail a summary of findings within a week and took his address. He hasn't received it.

On Friday, the VA said the hospital was waiting on a request from him.

During the meeting, hospital officials mentioned the Observer's coverage, so Alexander looked up the stories online. As he read, he realized "this investigation was much different than what they described. That blew me away."

He acknowledges the family would have been upset to learn in 2004 of problems with their father's care. But they would much prefer to have known all the facts upfront.

For almost three months, the family has struggled with shock, renewed grief and whether they wanted to speak publicly.

"The key thing we're after is to try to make some difference," Tim Alexander said, "to make sure this never happens again." -- Staff writer Peter Smolowitz contributed.

-- Stella M. Hopkins: 704-358-5173

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[goofycow]

This is news to me. What a sad story.

[Ron II]

Criminal negligence...

[Ricky]

Yep they gotta notify you. However, when an agency develops a regulation which is not open to any oversight and to take it one step further the same agency is removed from any accountability unless caught at something---------------- :) I assure you that they will make instant notification of any mistake they commit hahahaahhahahahahaha Oops forgot to mention instant notification as soon as they finsh with their 12 month search on ways to hide their mistake........Once they determine hiding the thing is impossible, they hit the hill greasing the skids prior to offically briefing congress. This allows them to brief on a day when most congressional seat holders spent the night before getting that last monthly roll with local ladies before they return home to their family and holiday dinner AND last but not least - gives them the knowledge that Ted Kennedy will be drunk during that session!!!!!Lets see that would turn out to be 364 days for on the other day he is in rehab hahahahahahahahahaha JUST KIDDING I think.......

[yoggie2]

Man, this is awful story. But really, the sad thing is if they shot the guy with a gun, there is no way you'd find out about it specially if they were doing the shooting. The care there isn't top skilled people at these places, its minimal at best. Do you think you would be receiving the best care at a VA Hosp. and the help is virtually not held responsible or any reprecusions for there actions or lack of. A story like this don't surprise me at all. Oops sorry about your dad hell, he was old anyways. This is really the answer he really got after looking for what the hell was going on with his dad dieing and damed sure wasn't going to call him and his family after finding right then they had move his death date up a few months by not putting back what they were taking out. As far as the nurse she working at another VA, they would never ever admit any wrong doing EVER.

[Chuck75]

Since I'm quite cynical when it comes to the VA--and one of the chief weapons the VA uses against veterans is delay--I would not expect the VA to release anything until it is forced to by law. This is particularly true if the release is likely to be embarrassing or will end up costing the VA & Gov. a fair amount of change. Obviously, this is a wrongful death and malpractice suit in the making, and a "cover up" occurred to compound the seriousness of the matter.

I just got this from The Charlotte Observer Web site and wanted to see if anyone else here knows if VA regulations require that patients and their families receive notification of mistakes with care? The article has no reference to a specific regulation, so I'm not sure if this is so. What say you, hadit fambly?

Cases like this are very sad:

VA's silence on death

brings grief, confusion for family

STELLA M. HOPKINS

shopkins@charlotteobserver.com

Tim Alexander picked up his dad from the Asheville VA hospital on a sunny fall Sunday for a cookout. He knew his father was dying, but that day was a good one. Don Alexander enjoyed Tim's birthday party with friends and family.

By Friday, he was dead.

For more than two years, the Alexander children wouldn't know the details about his final hours at the hospital's nursing home. Even then, they say, hospital officials misled them about what had happened.

Responses from the Department of Veterans Affairs to Observer questions about the case differ from agency documents obtained through Freedom of Information requests.

This spring, the Alexanders learned from Observer reports that their father's 2004 death followed a procedure performed by an untrained physician assistant. No one had told them that his death, at 73, was among the factors that prompted a VA investigation that year and led to admissions being suspended at the hospital's nursing home unit. They didn't know that investigators said the procedure was a mistake because Alexander's blood pressure was very low.

"I couldn't believe it," Donna Alexander said last week. "We were never given any indication that my dad's death was anything other than normal."

A VA spokeswoman said in an e-mail Friday evening that nothing the staff did contributed to or caused Alexander's death. A review by doctors determined that he received "appropriate" care, spokeswoman Karen Fedele said in the e-mail. VA documents show that the peer review was not as critical as a report by VA investigators but still found that "most experienced, competent practitioners might have managed the case differently."

Acknowledging mistakes

VA regulations require that patients and their families receive notification of mistakes with care. Alexander's case and other incidents make clear that doesn't always happen at the two main hospitals serving Charlotte-area veterans.In April, the VA told the Observer that the Alexander family "was not notified in a timely manner." On Friday, Fedele said the VA wasn't required to make any disclosure to the family.

During a congressional hearing in April, lawmakers chided Salisbury VA officials because the hospital had not shared word of care problems with seven patients. The Observer also has talked with two other families who were not told of problems that led to loved ones' deaths in Salisbury.

The VA didn't even respond promptly to a congressional request. During the April hearing, U.S. Rep. Mel Watt asked for details on the Salisbury VA cases. Last month, the Charlotte Democrat said he told the VA, "Your failure to respond is unacceptable." On Wednesday, his office said he still hadn't heard.

The VA said Friday that it had provided a response, but it didn't say when.

Medical mistakes, from faulty surgery to incorrect medications, are a leading cause of death, injury and illness nationwide. There also is a push to tell patients and their families about mistakes, any investigations and corrective steps.

Experts, including a former VA doctor, say the Alexanders' experience is egregious because they learned of problems from news reports and feel the hospital didn't provide complete information when asked.

"We found the vast majority of people would easily forgive you for making a terrible mistake if you acknowledge you made a mistake," said Dr. Steve Kraman, a VA doctor for 26 years and an early advocate of error disclosure. "You give people information that by rights belongs to them. You say what you're doing to prevent it again."

Doing otherwise destroys trust.

"You start to assume people are lying all the time," said Rosemarie Tong, head of UNC Charlotte's Center for Professional and Applied Ethics and a professor of health care ethics. "In a health care environment, if you can't trust people, it's pretty scary."

`They told me ... not to worry'

Don Alexander entered the Asheville VA in fall 2004 for hospice and nursing care as he battled heart disease.

On Oct. 25, 2004 -- the day after her brother's birthday cookout -- Donna Alexander visited their father for about 90 minutes. He sat outside in his wheelchair. The retired real estate broker and home builder had been listening to a recorded book on how to become a billionaire.

"My dad was sharp," his daughter recalled. "We had an amazing conversation."

His health problems included fluid buildup in his abdomen, which causes pain and can make breathing difficult. The fluid can be drained by making an incision and inserting a tube. He recently had this procedure, called paracentesis, at least twice. That week, on Thursday afternoon, he had a third.

Tim Alexander recalls seeing containers filling with fluid and wondering if it was safe to remove so much. His sister said she asked nurses several times why her father was so lethargic, barely opening his eyes.

"They told me what my dad was going through was perfectly normal and not to worry about it," she said.

She didn't know his blood pressure was dangerously low -- 58/34 at one point.

Reassured, she left around 8 to spend the night at her brother's house. Early the next morning, he got a call that their father had died.

"There's no question my father was on his deathbed, but ... I thought he probably had six, eight weeks, maybe 10," Tim Alexander said. "It just took a very quick turn, and now we know why."

`My dad died alone'

One month after Don Alexander died, an employee at the Asheville VA called the agency's medical investigators in Washington to warn of care problems. Investigators arrived within the week and reviewed four cases, including Alexander's and those of two men who died suffering extreme pain.On Dec. 17, the VA directed the hospital to suspend nursing home admissions, saying the staff didn't know how to care for dying patients. Some admissions didn't restart for eight months.

The Observer first wrote about the Asheville problem in March after obtaining the investigators' report through a Freedom of Information request. Patients' names were blacked out. The Observer identified Don Alexander through public records and contacted the family.

The report and other documents recently received detail Alexander's last day and investigators' conclusions.

At 3:24 p.m. on Oct. 28, 2004, a physician assistant performed the draining procedure on Alexander. His blood pressure was 63/32 at the time and fell lower by 4 p.m. VA investigators said the draining was a mistake because of Alexander's "profoundly" low blood pressure. The amount of fluid removed was unusually large, and he didn't receive replacement fluids.

By 2 a.m. the next day, nurses noted that he was bleeding, and his blood pressure remained very low. At 6:42, they wrote, he was "Trying to sit up and wanting to go to ER." Don Alexander died soon after.

"My dad died alone, and we were less than 10 minutes away," Donna Alexander said.

Investigators say the physician assistant was not trained in the procedure and was not "appropriately supervised" by a doctor. There was no follow-up with the patient by a doctor or the physician assistant. A Washington VA official has said that no one was fired "because no one was deemed incompetent and there was no malicious intent." The VA says the hospital took disciplinary action but wouldn't reveal what.

This April, Tim Alexander saw a brief mention in an Asheville paper about a man who had died at the VA hospital in 2004. The man had had a procedure to drain abdominal fluid.

He wondered: Could that man have been my father?

Grappling with the system

Alexander, a custom home builder, carried the news clipping around for a week or so. Finally, he called the Asheville VA to ask questions. They invited him for a meeting on April 18 to "express condolences and review the circumstances leading to his father's" death, VA spokeswoman Fedele said Friday.

A hospital official met Alexander when he arrived.

I guess you have figured out by now that this investigation involved your father, he recalls her saying during an elevator ride. No, he hadn't.

Two hospital officials talked with Alexander. He says he feels they misled him by describing the investigation as a routine, in-house follow-up after the death of a patient -- not a probe by VA headquarters' investigators.

Alexander, unfamiliar with the complexities of VA reporting, says officials did not make clear to him that there were two investigations. One was the routine peer review, the other an unusual visit by the VA Office of the Medical Inspector.

The inspector's office can handle most investigations from Washington using electronic records. Investigators only made on-site visits to hospitals 27 times in the past three years -- two of those within seven months to look at problems in Asheville.

Alexander says the hospital told him little about investigators' conclusions, only that they found no wrongdoing and made some staffing changes. He asked for a copy of the findings but was told he couldn't have it.

Peer review reports are protected by law. The inspector's report can be released. He said officials told him they would mail a summary of findings within a week and took his address. He hasn't received it.

On Friday, the VA said the hospital was waiting on a request from him.

During the meeting, hospital officials mentioned the Observer's coverage, so Alexander looked up the stories online. As he read, he realized "this investigation was much different than what they described. That blew me away."

He acknowledges the family would have been upset to learn in 2004 of problems with their father's care. But they would much prefer to have known all the facts upfront.

For almost three months, the family has struggled with shock, renewed grief and whether they wanted to speak publicly.

"The key thing we're after is to try to make some difference," Tim Alexander said, "to make sure this never happens again." -- Staff writer Peter Smolowitz contributed.

-- Stella M. Hopkins: 704-358-5173

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[Berta]

De ja vu-

Mu husband was the victim of countless medical errors that the VA could have resolved when they occured.

At one point after Rod had ECHO and other testing for heart disease the VA cardiologist told me there was nothing wrong with his heart.

When I prepared my FTCA claim I discovered that not only did the doctor know he had heart disease, he also knew it had been misdiagnosed by another VAMC for years already.

There was a major cover up in medical errors by the VA in Rod's case and they discharged him after a major stroke with an appointment ,minimal meds,8 months in the future.

We thought based on very few meds and this appointment so far away-8 months from discharge that the VA expected him to make a full recovery.

I now realise without any question or doubt that the VA doctors were hoping he would die before the next appointment and that I would never find the true cause of why he died.

I proved negligence- it was right in his clinical record.