Report Summary

Title: Healthcare Inspection – Review of a Patient with Medication-Induced Acute Renal Failure, Amarillo VA Health Care System, Amarillo, Texas
Report Number: 13-01988-253
Issue Date: 7/29/2013
City/State: Amarillo, TX
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 Office of Healthcare Inspections conducted an inspection in response to Congressman Randy Neugebauer’s request to review an allegation that a patient at the Amarillo VA Health Care System, Amarillo, TX, received negligent care resulting in permanent kidney damage, which led to multiple other medical problems. It was alleged that: (1) A patient with a history of renal cell carcinoma who had his right kidney removed was rescribed medication that led to a 4-day hospital admission for acute renal failure (ARF). (2) The patient now has permanent damage to his remaining kidney as a result. (3) Other medical problems have resulted from this kidney damage. We substantiated that a newly prescribed blood pressure and cardiac medication, lisinopril, contributed to or caused the patient to develop ARF. However, in view of the totality of the patient's medical condition, we concluded that the lisinopril prescription was justifiable. We did not substantiate that the patient has permanent damage as a result of the ARF or that the patient’s current medical problems are a result of the ARF.
We recommended that the System Director consult with Regional Counsel to determine if disclosure of the events related to the patient’s episode of ARF, as discussed in this report, is indicated and that the Chief of Staff conduct a thorough review of the care provided to this patient by the system.