At the U.S. Department of Veterans Affairs (VA), the agency entrusted with the delicate care of our nation’s brave veterans, officials have buried medical workers’ deadly misdeeds for years.
According to a months-long USA Today investigation, VA hospitals’ doctors and staff have been getting away with up to dozens of mistakes each. These practitioners were not fired. In some cases, they weren’t even reported. They were instead allowed to slip quietly away and practice elsewhere.
USA Today’s report opens with the story of Thomas Franchini, a podiatrist who once practiced at the nation’s largest veterans’ hospital, Togus VA Medical Center. Franchini was responsible for 88 botched surgeries, including 2 on a patient who ended up in enough pain to need her leg amputated. The first of those 2 surgeries was in 2006. It wasn’t until 2013 that the VA informed this patient and others of its investigations on Franchini, who had resigned 2 years prior. He’d moved to New York, where he still practices today.
Investigation Uncovers Years of Unacceptable Secrecy
Over the course of its investigation, USA Today reviewed hundreds of records dated between 2014 and 2015 – representing only a fraction of VA medical errors discovered over the past decade.
The VA first failed its patients by failing to report problem doctors to state regulators and the National Practitioner Data Bank, the database of medical errors that healthcare organizations refer to when hiring. But the investigation also dug up 230 secret settlement deals VA hospitals struck with bad doctors, worth a collective $6.7 Million. These allowed doctors to resign with clean references, no matter how serious their mistakes.
At least 126 cases involved fireable offenses. In nearly 75 percent of these cases, the VA agreed to purge any evidence of misconduct. Even in 70 cases that resulted in employees’ lifetime ban from VA hospitals, the agency kept reasons quiet, and cases reported to the states were delayed by years. During these long periods, the VA helped doctors leave their sordid pasts behind for jobs and licensure in other states, knowing the risks to the lives of each offender’s future patients.
VA Medical Errors Result in Anything from Inconvenience to Death
While USA Today conducted its investigation, the VA was already under fire for its backlog of over 800,000 unprocessed veterans’ benefits applications. Nearly one-third of veterans hoping to enroll in these programs were left to die waiting for care.
Subsequent scrutiny led the VA to declare tighter regulation of its employees and increased transparency. But even as the agency dropped hundreds of employees from its payroll, the details of these dismissals remained hidden.
Now, we know at least some. We know about a nurse who left a psychiatric patient in leather restraints for hours, for example, and a hospital director who harassed female workers while his patients waited weeks for appointments. We know about 1 radiologist who failed to detect tumors and blood clots in dozens of CT scans and was paid $42,000 to resign; another hospital director was paid off with $163,000 after killing a patient with a cocktail of 13 drugs.
Why Is Workers’ Discipline Less Appealing Than Veterans’ Endangerment?
Before these cases emerged and patients’ lawsuits gained traction, the VA blamed its secrecy on a policy that exempts officials from reporting certain kinds of healthcare providers, including nurses, physicians’ assistants, and podiatrists. The VA also cited its employees’ privacy as more important than the public’s right to know about their mistakes – in other words, more important than protecting veterans.
This willingness to sacrifice veterans’ health can only be described as an insult to the sacrifices veterans made for the good of our country. The suffering veterans now endure from those sacrifices – which gave us all, VA officials included, the freedom we enjoy today – has been neglected.
In response to the report, the VA again promised more transparency. VA Secretary David Shulkin will expand the policy to require the agency to report all (rather than only certain types of) clinicians in the future and to require senior officials to approve more employee settlements.
Until then, the VA’s policy on medical errors is clear – inform patients as soon as possible – but still contains gaping holes. To this day, you won’t find any record of the Franchini investigation at the National Practitioner Data Bank (NPDB). The VA never reported it.