VA Medical Malpractice: Preventable Mistakes?


. By Jane Mundy

Several years ago, a survey from the Institute of Medicine titled "To Err is Human" reported that 48,000 to 98,000 Americans die each year from preventable mistakes, mainly from drug mix-ups and inattentive treatment. And more medical errors occurred in the hospitals run by the Veterans Health Administration. Fast forward to 2008 and given the amount of complaints and lawsuits filed against VA hospitals, not much has changed since 1999.

That startling statistic (even the lower figure) ranks hospital errors as the eighth most frequent killer in the US, resulting in more fatalities than car crashes. And more than 7,000 Americans a year die from avoidable medication errors—more deaths than from workplace accidents.

Why is the rate of human error so high, particularly in VA hospitals? One reason could be that VA doctors don't need to purchase malpractice insurance because the government compensates patients harmed by a physician's negligence. One case in point:

in 2007, a surgeon with a history of malpractice complaints in Massachusetts was involved in "aggressive, complex surgeries" at a Veterans Affairs medical center in southern Illinois that went beyond what that site could handle, resulting in a spike in deaths at the hospital.

The VA hired Dr. Jose Veizaga-Mendez, despite his being barred from practicing in Massachusetts after accusations of grossly substandard care. During his time at the VA hospital, nine people died during a six-month period when the typical mortality rate would have been two. It was later discovered that those deaths were due to "aggressive, complex surgeries that were beyond the normal capacity of the Marion VA hospital," which meant the surgeries were beyond the surgeon's expertise, the equipment was insufficient, or there were not enough medical personnel.

The widow of one of Veizaga-Mendez's patients filed an administrative complaint with the VA. Her husband died after gallbladder surgery. Veizaga-Mendez surrendered his Massachusetts medical license in mid-2006, and told VA administrators that he didn't want to pay the licensing fees. As well, there was a malpractice suit against him in Massachusetts. Apparently, the doctor had a long history of medical malpractice cases and claims. Yet the VA still hired him.

Tony B. says that he has been at odds with the VA for years regarding his medical issues. He is on disability and wishes he could afford a civilian doctor. "The way the VA handles things is unbelievable, the crap you have to go through," says Tony. "I did find a civilian doctor who could help with my particular problem but he charges $800 per hour. So I'm stuck with the VA hospital."

Tony was given Botox treatments to help with Tardive dyskinesia—in his case, involuntary movements of in his face. Botox helped the spasms and it worked well for a few years but then he was switched to Myobloc. "A plastic surgery intern gave me the shots," he says. "First off, they were extremely painful. It hurt way more than Botox. I asked her to slow down but she did the last two jabs very quickly and walked out of the office. I even heard her complaining that she was late for lunch."

Tony says that he was never told about the side effects of Myobloc and he has been suffering from dry mouth, dry eyes and numbness in his arms for months.

"I talked to the VA pharmacist and asked if there any side effects listed on the label. He said yes, but the doctors at VA don't read the label information. The biggest problem is that they didn't wait four months in between giving me Botox and Myobloc—I found that on the manufacturer's site—and I talked with a customer rep at Allergan (the manufacturer).

"Then I phoned the FDA and was told the same thing—I couldn't switch from Botox A to Myobloc (Botox B) without waiting four months. When I confronted the VA intern with this information and the side effects I was having, she told me that I shouldn't be concerned and my symptoms didn't come from Botox. I called that BS."


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