Report Summary

Title: Healthcare Inspection - Alleged Poor Surgical Care and Mismanagement of Adverse Events VA Medical Center, West Palm Beach, Florida
Report Link: http://www.va.gov/oig/pubs/VAOIG-12-01287-208.pdf
Report Number: 12-01287-208
Issue Date: 6/22/2012
City/State: West Palm Beach, FL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted an inspection in response to an anonymous survey respondent’s allegations of poor surgical care and inadequate follow-up of adverse outcomes at the West Palm Beach VA Medical Center. We did not substantiate that three patients experienced adverse outcomes because a ENT surgeon did not possess the necessary qualifications or competence to care for otolaryngology patients. We also did not substantiate that the surgeon exercised poor judgment. The ENT surgeon met competency expectations, he was appropriately privileged to perform the surgeries in question, and his performance was periodically reviewed as part of the reprivileging process. We found that reporting and evaluation of adverse events needed improvement. Surgical staff did not appear to understand the requirement to report serious adverse events or to use the correct disclosure template. We made two recommendations related to staff training and disclosure of adverse events.