By Suzanne Gordon, VHPI Senior Policy Analyst
In recent months, the VA’s Office of Inspector General (OIG) has released two reports detailing serious threats to patient safety in several medical facilities. First, on May 11, the OIG released a report on “care and oversight deficiencies” around numerous homicides at a medical center in Clarksburg, West Virginia. Then, on June 2, the watchdog issued another report focused on “pathology oversight failures” inside the VA system of the Ozarks in Fayetteville, Arkansas.
To be sure, these investigations indicate inexcusable management issues. And yet many observers have concluded that the VA is unique in its failure to reign in homicidal or impaired staff.
Nothing could be further from the truth.
The problems of serial murder by healthcare professionals, as well as patient harm resulting from impaired staff, exists throughout America’s private healthcare system.
Let’s first question the framing of serial murder inside the VA. The OIG investigated the actions of a nursing assistant, Reta Mays, who allegedly killed seven patients by deliberately administering them insulin. According to the report, Mays said, “she administered insulin to patients she believed were suffering so that they could pass ’gently,’ and because she had a lot of stress and chaos in her personal and professional life.”
The report details serious failures in management and oversight. Staff, for instance, failed to adequately monitor her hiring and performance, oversee medication management and security, or conduct clinical evaluations of unexplained hypoglycemic events.
In short, many staff members failed to engage in the kind of routine cross-monitoring and reporting processes that would have allowed them to catch the problem before it became catastrophic. Critically, a mortality work group created by The Chief of Quality and Risk Management did not meet consistently “due to busy schedules and competing priorities.”
Although tragic, this is hardly surprising given the fact that a 2018 OIG report catalogued serious staff shortages at the Clarksburg facility. Although the OIG report on Mays’ actions does not mention the issue of physician and nurse staffing, we know from patient safety literature that staff shortages mean that overburdened nurses and doctors are often unable to reliably perform critical patient safety activities. Health care workforce researcher Linda Aiken, has, for example, done myriad studies connecting nursing staffing to patient mortality and morbidity throughout America’s private healthcare system. Her take home message is that understaffed wards with few registered nurses leads to more patient deaths. Under-staffing impacts inter and intra-professional communication as well as the ability of staff to adhere to various patient safety policies and procedures.
The second OIG report on pathology problems in Fayetteville, Arkansas focuses on the Path and Lab Service Chief, Dr. Robert M. Levy. He allegedly misdiagnosed patients’ pathological specimens that, according to the report, “adversely affected outcomes.” Levy also apparently altered quality management documents to conceal his errors. Similarly, the OIG notes that that a facility leader did not adequately monitor Levy’s clinical practice and failed to investigate his alleged misconduct. Levy, who later admitted to being an alcoholic, worked while impaired, and managed to avoid the VA’s mandatory screenings for substance abuse. His conduct caused preventable harm to many veterans. He has been subsequently fined and imprisoned.
What these reports leave out is any discussion of the broader problems of serial murder and patient harm due to impaired providers in the non-VA healthcare system.
This pattern is well-discussed in a paper entitled “Serial Murder by Healthcare Professionals,” which was co-authored by former VA Under Secretary for Health Kenneth W. Kizer. In it, the authors discuss the problem of serial murder by healthcare staff as “poorly understood,” and often underestimated. They make clear that the issue demands “systematic changes in tracking adverse patient incidents associated with the presence of a specific healthcare provider.”
In another paper, Kizer and Beatrice C. Yorker,, Professor Emerita of Nursing and Criminal Justice & Criminalistics at Cal State University, Los Angeles, bluntly state that serial murder in healthcare is a “patient safety orphan.” In their study of this phenomenon, Kizer and Yorker found that serial murders have been reported in 21 countries and 22 states in the America. Cases are not only notoriously hard to prove, but healthcare professionals have not been adequately trained in how to identify the problem and mechanisms have not been set up to adequately deal with it.
They mention one of the most notorious serial murderers in American healthcare history -- nurse Charles Cullen, who confessed to murdering more than 40 patients in New Jersey and Pennsylvania over his sixteen-year career. (It is, however, thought that he may have killed many more patients – as many as 400.)
In his book “The Good Nurse,” author Charles Graeber details how Cullen was passed around from hospital to hospital similar to a pedophile priest moved from parish to parish. Numerous hospitals suspected that he was guilty of patient deaths but failed to stop him because they felt they lacked proof, but also because they were concerned but about their reputations. One hospital, Somerset Medical Center, refused to give police investigators relevant patient records and lied to them.
Another notorious killer was surgeon Jayent Patel, who was dubbed “Dr. Death.” Patel was implicated in 87 patient deaths. As described in “When Chicken Soup Isn’t Enough: Stories of Nurses Standing up for Themselves, their Patients and their Profession,” Australian nurse Toni Hoffman uncovered Patel’s sorry history when he left the U.S. to work rural Southeast Queensland in 2003.
Hoffman quickly noted that Patel’s patients were developing serious complications, and some were dying. (Patel was also performing unnecessary surgeries, some of which should have been done in larger, better resourced hospitals.)
Hoffman and her nursing colleagues complained about Patel. But their concerns went unheeded and their professional futures were jeopardized.
Desperate, Hoffman contacted a journalist who Googled Patel. According to the book, the reporter found that “his problematic history dated all the way back to 1981. He had first been disciplined for falsifying records and relinquished his license to practice in 2001 rather than face prosecution. He also had the dubious honor of being the most sued surgeon at Kaiser Permanente in Portland, Oregon.” Patel later fled Queensland for America and was extradited. But after lengthy legal proceedings, Patel was given a plea deal in which he avoided jail and was barred from practicing medicine in Australia.
There also exists extensive literature pointing to the prevalence of private healthcare staff who have addiction problems that led to patient harm.
One of the most famous physicians with addiction problems was internist Michael Palmer, who became a best-selling mystery writer after he had his hospital privileges suspended and was put on two years’ probation for writing false prescriptions to support his drug habit.
There was also the outrageous case of Harvard-trained orthopedic surgeon David Arndt, who walked out of an operating room during spinal surgery so he could cash a paycheck. (Arndt, who eventually served time in a federal prison, was seriously addicted to a raft of different drugs.)
Other serious patient safety problems exist in the private sector, where fee-for-service medicine pushes physicians to prioritize profit over patient safety. The Boston Globe’s Spotlight Team, for instance, did a series on the phenomenon of “concurrent surgeries.” Essentially, surgeons double-booked patients for complicated surgeries at the same time, then moved from Operating Room to Operating Room to get both procedures finished. This practice has been deemed unethical. It is banned in some hospitals but routine in others – including some of the most prestigious ones in America, like the Cleveland Clinic.
As reported in my book “Wounds of War,” one of the patients who suffered from a concurrent surgery was David Antoon, a Vietnam veteran who tried to sue the Cleveland Clinic and his surgeon for a botched prostate cancer surgery.
The surgeon, Antoon alleged, failed to be in the operating room during crucial parts of the operation. Instead, he was supervising multiple operating rooms and let a non-credentialed doctor-in-training do the surgery, even though Antoon had been assured in writing that the attending surgeon would perform the operation. As a result of the surgery, Antoon, a pilot for United Airlines, suffered severe complications, disabilities, and lost his job as an airline captain.
Antoon’s case was not allowed to go to trial. Antoon is now cared for by the Dayton VHA. The VHA, he says, “is the model needed for this country—a system where patients and providers have the same goal— positive patient outcomes.”
One of the things Antoon values most about the VA is the fact that it is a national model for healthcare transparency. We know about problems in Clarksburg, West Virginia and Fayetteville, Arkansas because the VA is highly monitored by Congress and its own OIG, as well as covered by the media.
This is not true in the private sector. Even when patients win legal actions against hospital or providers for documented malpractice, most legal settlements are accompanied by nondisclosure agreements. As legal researcher Michelle Mello, a professor of law and health policy at Stanford University, has stated:
Nondisclosure agreements that prohibit plaintiffs from talking to regulatory bodies, like state boards of medical licensing, about what happened to them are really objectionable. Patients shouldn’t have to choose between accepting compensation and acting on a perceived obligation to try to ensure the physician doesn’t hurt someone else.
Clearly the VA should institute processes and procedures to assure that veterans are not harmed by staff in any way or for any reason. This should include greater attention to hiring and performance, rigorous monitoring, and far more attention to safe staffing and team processes that assure reporting of problematic behaviors and events. At the local, regional and national level, VA managers and administrators, as well as Congress, should also be far more focused on improving care inhouse rather than devoting staff time and money on a mission impossible: monitoring and coordinating care with private sector providers who are not interested in or required to collaborate and coordinate with VA staff.
Reports like those released by the OIG on problems in the VA are critical resources and spurs for positive change. The danger, however, is that Congress, the media, and the public forget to ask the crucial question that must inform all debates about how to best serve veterans That is, compared to what? Even when it comes to egregious instances of patient harm, the VA is still quicker to act and remedy problems than the private sector.