Healthcare Inspection: Alleged Mismanagement of Resources and Patient Safety Issues, VA Northern Indiana Health Care System Fort Wayne and Marion, Indiana

摘要

The VA Office of Inspector General, Office of Healthcare Inspections received allegations regarding mismanagement of resources and patient safety issues at the VA Northern Indiana Health Care System (the system) in Fort Wayne and Marion, Indiana. The purpose of the review was to determine whether the allegations had merit. The complainant made the following allegations pertaining to: persistent instrumentation problems with Operating Room (OR) sets and peel packages; ongoing reusable medical equipment issues; Supply, Processing, and Distribution (SPD) stocking and dating of supplies; pharmacy stocking of Operating Room, Post Anesthesia Care Unit, Endoscopy Unit (OR, PACU, EU) medications; and management issues. We substantiated the allegation that OR sets and peel packages continue returning from the Marion campus SPD incorrectly as previously noted by a number of external reviewers. We substantiated the allegation that SPD technicians were unable to identify instruments, and pictures of instruments to assemble instrument sets, as previously recommended, would have been helpful. We did not substantiate that two new HQ180AL model endoscopes were damaged by improper handling. We were unable to substantiate or refute the allegation that leak testing was not consistently done on the B-K 8800 rectal probe. We did not substantiate that endoscopic procedures must be conducted in the small OR because the air handling system in the larger ORs cannot pass inspections. We did not substantiate the allegation that assigned OR, PACU, EU supply technician was reassigned numerous times to cover the entire hospital so no one administered Integrated Funds Control Point Activity, Accounting and Procurement labels and routinely monitored for outdated supplies. We substantiated the allegation that an ankle fusion procedure, which required an implant, was canceled and rescheduled three times, however we did not find that cancellations were all related to the systems inability to provide the implant and instrumentation sets. We were unable to substantiate or refute the allegation that pharmacy technicians remove expired medications and dont always replace them.