Communication Failures May Have Caused Patient Deaths at a VA Medical Center

The VA Inspector General released a report with a very disturbing finding: failures in communication between two medical departments may have adversely affected patient care in the Salt Lake City VA health care system. The report did not, however, link those failures to any patient deaths. 

The failures in communication occurred between the Interventional Radiology department and vascular surgery residents. The failures caused a delay in care which ultimately led to at least 1 patient’s death, according to the complainant. At the VA medical center, a 2-week suspension on vascular surgeries and interventional radiology procedures followed these deaths. 

In a separate but seemingly related incident, a failure between these same 2 departments may have resulted in the death of a 70-year-old patient. The VA saw these instances as places where they can improve their service and launched a full internal investigation. Despite these occurrences, the VA Inspector General was awed with the internal investigations that were conducted as well as the system checks the VA utilized during the investigation. 

One thing the VA Inspector General did not do in his report was validate the link between the failure in communication and patient deaths in 2 other patients. Beyond the failures in communication, The VA medical center is also charged with performing unnecessary amputations. While the VA medical center performed 3 times the number of amputations in 2009 than in 2008, the VA Inspector General ascribed this increase to a simple rise not only in patients, but more surgeons, inside the VA medical system.