Surgical Adverse Clinical Outcomes and Leaders’ Responses at the Columbia VA Health Care System in South Carolina

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations of adverse clinical outcomes related to three patients’ surgical or invasive procedure(s) at the Columbia VA Health Care System (facility) in South Carolina. The OIG substantiated three patients experienced adverse clinical outcomes related to their surgical or invasive procedure(s). The OIG found quality of care concerns with two of the three patients however, no quality of care concerns were identified for the third patient who experienced complications following a surgical procedure. A medical intensivist incorrectly placed a chest catheter and a thoracic surgeon incorrectly placed a chest tube while attempting to drain a patient’s pleural effusion. The OIG found that clinical care deficiencies made by the intensivist and surgeon led to a series of unplanned events that contributed to the patient’s death. The OIG identified deficiencies in the peer review and quality management processes. A vascular surgeon conducted a wrong site surgery when amputating a patient’s third versus fourth toe. The OIG found that although removal of the patient’s third toe was clinically indicated due to infection, the surgeon failed to acknowledge and discuss the deviation from the informed consent and pre-operative plan with the patient and surgical team. Leaders failed to address the surgeon’s undermining of patient safety protocols and high reliability organization principles. Additionally, the OIG identified deficiencies in practitioners’ and surgical nurses’ compliance with informed consent and time-out protocols. The OIG made one recommendation to the Veterans Integrated Service Network Director regarding a comprehensive review of a patient’s care. The OIG made six recommendations to the Facility Director related to medically-complex patients, peer review practices, timeliness of institutional disclosures and internal reviews, the vascular surgeon’s disregard of patient safety protocols, and informed consent and time-out protocol compliance.