Report Summary

On March 21, 2017, a confidential complainant forwarded to the Office of Inspector General (OIG) documents describing equipment and supply issues at the Washington D.C. VA Medical Center (the Medical Center) sufficient to potentially compromise patient safety. OIG promptly reviewed the documentation. On March 29, 2017, OIG deployed a Rapid Response Team to assess the allegations. OIG’s team conducted interviews, collected documents, and conducted a physical inspection of the Medical Center’s satellite storage areas on March 29–30, 2017. The team returned for an additional site visit on April 4–6, 2017, and is on-site for a third inspection at the time of this report’s publication. OIG has preliminarily identified a number of serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk. Although we have not identified at this time any adverse patient outcomes, we have found other issues. At least some of these issues have been known to the Veterans Health Administration (VHA) senior management for some time without effective remediation. Although our work is continuing, we believed it appropriate to publish this Interim Summary Report given the exigent nature of the issues we have preliminarily identified and the lack of confidence in VHA adequately and timely fixing the root causes of these issues. We are also including recommendations for immediate implementation.