Report Summary

Title: Healthcare Inspection - Alleged Questionable Surgical Care in a VA Health Care System
Report Number: 12-03743-184
Issue Date: 5/1/2013
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The OIG conducted an inspection in response to allegations that a VA Health Care System specialty service surgeon had licenses suspended in two states and had several near misses some related to wrong site surgeries, and that the Chief of Surgery declined to review two alleged sentinel event cases or take action on reported staff concerns. We did not substantiate that the surgeon had suspended medical licenses in two states or had several wrong site surgery “near misses.” We identified one case with which we had concerns regarding the quality of surgical technique. While the Chief of Surgery declined to review two alleged “near miss” cases as sentinel events, we concurred that the cases did not meet the definition of a sentinel event. The Chief of Surgery had taken multiple actions to address staff’s concerns regarding the surgeon’s surgical techniques. The system did not delineate the surgeon’s privileges, the privileges were not facility or provider specific, and an initial focused professional practice evaluation was not completed as required. We recommended that the system Director ensure the two alleged “near misses” are referred to quality management staff to determine if action should have been taken, consult with Regional Counsel regarding possible clinical disclosure to the patient for whom quality of surgical technique concerns were identified, ensure that initial focused professional practice evaluations are completed on all newly hired providers, and that privileges are facility and provider specific. The Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided acceptable action plans.