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Adverse Event Disclosure



Good evening members. I am going to share with you an event that I've had scheduled last week at the VA in Tucson.

One year ago , last March 17th I was scheduled to have a brain tumor removed in the VA. Soon as they administered the Anthesia drugs, I basically died. Lost of oxygen , blood pressure , ect. They brought me back and aborted the surgery . I awoke in ICU, which they booted me out and sent me home an hour later instead of keeping me for observation overnight
Members, there is a thing called adverse event disclosure . Look it up and read it. I asked to have that done, and the VA refused and threatened me saying I already received one in the ICU, This calls for a formal one, meeting with the head of the surgery dept, ect. I wrote letters to two congressman and the OIG. They lied and covered up and refused to have a formal one. Well, I contacted the undersecretary of the VA in DC, in charge of all hospitals. I had that meeting with the Chief of Staff and head of the anthesia dept, Certain medications interacted with the Anthesia, drugs which were supposed to be stopped prior to surgery. They covered that up and stated they told me even though there is no record. I had the only record which a doctor used yellow post stickers with 2 other medications listed , not the ones that the Anthesia doctor told me in ICU, that should have been stopped. Aldo she had multiple patients she was getting ready for surgery not one per patient like there should have been. So yes, they are deeply upset I went over there head. It puts a black eye on them as this us an official record own letting everyone know what happened. Once again , they really missed with the wrong person. I contacted the General, Allison Hickley another VA under secretary who helped get me my 100% p & t TDIU effective last October within 2 days once I contacted her.
If a situation similar to mine occurs , don't hesitate to do this as well. I was able to get the chief to admit the truth and asked what are they doing different to prevent other veterans from going through this . And finally ,I requested them to outsource any surgeries I may need in the future to other hospitals .as I surely wouldn't trust them ever again! They stone walled and said it would be up to there business office on this matter, which is another lie. I will contacted the Under Secretary next week to state this issue to them and see if I can get this approved and placed in my record!

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Good for you Coolbreeze.....!!!

you know I have;'been there, done that' myself and you are correct that all VA patients need to know these things.

And if they are are both veterans, as well as employees, they MUST make sure their treatment from VA is for them, as a Veteran, not a VA employee..a big reason why my husband is in a grave.

(The M21 for VA doctors circa 1988 was some of my prime facie FTCA evidence)

Department of Veterans Affairs
Veterans Health Administration
Transmittal Sheet
Washington, DC 20420
October 2, 2012


"Disclosing Adverse Events to Patients"


Due to contacting Ms. Hickey, my VARO immediately adjudicated my 2 claims and denied them.
They have been sent to VA Central and someone there who has them and the files told me last week he would get back to me this week.

He will see the unusual adverse events that happened to my husband,as well as the obvious malpractice .But one is something VA never really considered before.

One is a 1151 claim I filed in 2012 (I am still eligible for accrued) and one is a CUE against a 1151 award of a CUE they made in 2012, that I filed in 2012.

In my FTCA info that I obtained under FOIA after the settlement., the Chief Cardio VACO opiner said'the nurses were far more observant than the doctors"
and that was true.

I knew of one adverse event only because a VAMC nurse pulled me aside and told me about it privately and said "look I could get fired for this but get Him out of here before they kill him"

She was relieved to know what had just happened between me and his doctor (I threatened the doctor to give him a CT scan)

and he was being prepped to get to Syracuse VAMC by ambulance.

Get this...to deny my claims someone at Buffalo VARO did a 'medical review' and every statement in it is false based on the established med recs as well as a VACO prior opinion from a cardio doctor...regarding a confirmed medical error involving his prescribed meds and his HBP that OGC and VACO stated "contributed to his death " 20 years ago.

Next thing I know they might try to get a VA opinion saying he isn't even dead.

I sure hope others read your cautionary advice.

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Thank you for bringing this to our attention. Im sure this kind of thing happens much more than we know.

The only thing I have to add is this:

The first thing you should do is to order, as soon as practical, your medical report of the issue/surgery. Then read it over. If the report is inaccurate, bring it to the doc's attention and ask him to correct it.

(I think its a good idea not to "attack" the doc..at least until you have given him the "benefit of the doubt" including an opportunity to correct an inaccurate report. It could well be an oversight..remember the doc has many assistants, and a portion of the report may have been inadvertently omitted due to a clerical error.)

By going to the doc with the assumption he is truthful and would want to correct such an error, you can often have his much needed cooperation in straightening out this error.

If, after you ask him to fix this and he continues the coverup, then you still have an opportunity to go on the attack, if necessary.

In my life, I have sometimes launched a premature attack on someone and found out it was my error, and regretted it. Fortunately, I have contacted these people to the extent possible and offered them my apologies. In the end, a lack of forgiveness on your part almost always hurts you more than your enemy, and is never a good idea. Forgive them, but hold them accountable. I see this on TV. Someone confesses to killing someone, and expects the state to forgive them. They may forgive, but they will still hold you accountable and you still have to pay the time for your crime.

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In my particular situation, the VA had no documentation of what medications I was supposed to stop prior to this surgery, I was the only that had the evidence, however it was written on yellow postage stickers not on a official document.And, a few important medications to be stopped weren't listed as they failed to inform me. This was my 4th strike of almost dying in a hospital due to my medical conditions. 1st for the VA even though they were informed I was a high risk and had provided them all records from previous issues in the hospital. I was advised I could file a tort against them which I won't as I am done fighting them. I have my 100% rating now and no longer work. Trying to get my ssd, approved with the help of an attorney as I was denied twice. When the judge sees the documents all written by VA doctors and my VA counselor stating I can't work at any job, it should be approved. How can one go to work taking oxy pills and 1500 mgs, of Gabe tin - as well with 15 medical conditions is beyond me.

I have my own group which I started 6 months ago teaching vets about there benefits with VA (1500) and my humor group for veterans (12500) with no profanity or politics as my hobby now. I will be here a bit more now !

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"I was advised I could file a tort against them which I won't as I am done fighting them. I have my 100% rating now and no longer work"

If you file under 1151 and succeed, then with the 100% you have now, they have to pay the additional 1151 award separately.

This is part of what I am fighting about now.

In 2012 I won 2 CUE claims.
The result of one claim ( 20 years after the disability occurred)
was an accrued award because they granted my dead husband 100% for a Sec 1151 stroke.
They paid 100% plus SMC, vet,wife, child,
for 6 months under 1151.

Th veteran had established 100% P & T for SC PTSD..(100% for SC plus 100% for 1151 "as if SC" equals

200% in monetary award.

The CVA regs say 100% for 6 Months, and then rate the residuals.
No residuals were rated or paid. (2012)

They did pay along with that the AO IHD Nehme award.

I cued that.
Recent decision.about 2 weeks ago
Cue granted, husband was 100% for 22 months under 1151. Yippee.

All of my evidence stated he was P & T.
But they said I was not eligible for the accrued additional amount. because I already received accrued

No regulation or reason cited. .WTF?

I am eligible for accrued benefits until I croak.

I cued them again.
Heard from VACO ,they received the claims,and 10 volume vaola files.
...............praying they can read.

I posted the 100% SC plus 100% 1151 regs here some time ago.
1151s depend on the same evidence as a tort.
Torts involve a cash payout.but can be offset against any 1151 awards.

It is often a better move to file under 1151 then under FTCA and 1151.

I got my tort offset refunded in 2010 ago but that story is here elsewhere.First of it's kind award that I know of.

The VA did do the right thing by advising you that you could file a tort claim.

Edited by Berta (see edit history)
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Keep up the good fight Ms Berta & COOL BREEZE


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COOL BREEZE keep kicking ass.. they sure need it. lying and deception has become a culture of standard procedure at VA.

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Cool I narrowly missed an adverse incident last Friday with the VA I had an EKG prior to having some GI scopes I never heard a word about it but on the day of the scopes I brought it up and asked it anyone looked at it. Well they looked at it and my heart rate was not like by the DOC so all scope were cancelled. I was sent over to my PCP and low and behold once I see the Doc first words out of his mouth is you are here to get you Plavix refilled right. No Doc I don't take Plavix he you sure then he corrected himself and said sorry I am on the wrong record you are not 58 either. Anyway all this earned yet another nuclear stress test, echo cardiogram and halter monitor.

I have a great fear of the VA putting me under and killing me to get another 90%er off the books they are not helping this fear.

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I have had my foot up there ass for years and they hate it. Lately when I ask for something I get it. I AM working on another foot up even deeper. Going to send a message to the Va under secretary requesting my record to be flagged in case I need another surgery or procedure requiring anthesia- -to have this done elsewhere due to the prior incident and me and my family have no trust 8 them in not trying to kill me again.

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