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Healthcare Inspection – Review of a Patient with Medication-Induced Acute Renal Failure, Amarillo VA Health Care System, Amarillo, Texas

Report Information

Issue Date
Report Number
13-01988-253
VISN
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

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.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director consult with Regional Counsel to determine if a disclosure of the events related to the patient's episode of acute renal failure, as discussed in this report, is indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that the Chief of Staff conduct a thorough review of the care provided to this patient by the system.