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Haley VA center error cost patient's life, report says

The VA inspector general also cites flies in operating rooms and contract issues with USF.

Published October 26, 2006


TAMPA – One patient died at James A. Haley VA Medical Center because of an error during surgery and some surgeries were canceled because doctors didn’t show up, according to a report issued Thursday.

The findings also said the hospital’s operating room was closed twice because of fly infestations and that staff responded by installing “suspended electric flying insect traps.’’

In addition, the 31-page report by the Inspector General of the Department of Veterans Affairs raised questions about the legality of a contract for surgical services between the University of South Florida and Haley, the nation’s busiest VA hospital.

Investigators recommended that Haley review all contracts with USF to ensure that the contracts are properly administered.

VA spokesman Phil Budahn said Thursday the agency already was taking appropriate actions to address problems identified in the Haley investigation.

“We will continue to monitor the situation to ensure timely implementation of these actions,” he said.

The inspector general began its investigation in February after stories in the St. Petersburg Times revealed several allegations contained in an anonymous four-page letter.

Separately, the VA recently completed an internal review of hospital director Forest Farley. Results of that investigation have not been made public.

Investigators did not substantiate all of the allegations in the letter but documented multiple problems. For example, investigators confirmed that a patient died at the hospital during surgery in 2002 because of an employee error.

The report provided neither the identity of the patient nor specifics of the case. It did say Haley responded appropriately after the death.

“The medical center conducted an internal quality review; in addition, they took appropriate actions based on their findings to prevent further occurrence,” the report said. “The medical center also disclosed the event to the family.”

Investigators substantiated that surgeries routinely were delayed because surgeons were not in the operating room.
In 2005, 5,423 surgical procedures were conducted. Haley recorded 1,040 surgical delays totaling 22,918 minutes, or about 15 days. In at least two cases surgeries were canceled because the surgeon was not available.

The inspector general found that on two occasions managers closed the operating room “because of the presence of flies.”

“Timely sanitary and pest control procedures were implemented, including temporarily closing the OR to protect patient safety,” the report said. “The Pest Control Technician also responded immediately.”

Haley serves 435,442 veterans in a seven-county area. According to investigators, it cannot meet patient demand with its eight operating rooms.

To improve operating room efficiency, Haley brought in a VA consulting team from outside the region. The team “noted that the demand for services exceeded the medical center’s capacity, signaling a rapidly approaching crisis.”

“We concluded that the surgical service was constrained by a staffing model intended for an 8-hour day, an OR suite built to sustain a much lower case load, and bed availability for a much smaller veteran population,” the report said.

Haley is in the process of expanding to 10 operating rooms.

Investigators documented other problems in the operating room. They concluded that some staff members were completing forms for monitoring anesthesia before surgery instead of during surgery, as is required.

In addition, investigators substantiated that Haley’s anesthesiology service was understaffed because Haley was unable to recruit anesthesiologists. The problem was a shortage of anesthesiologists nationwide and low pay at the VA.

In the private sector, an anesthesiologist can earn between $282,212 to $453,000 a year. At Haley, the pay scale ranges from $90,000 to $255,000.

Investigators concluded that the heart surgery program at Haley has a high death rate but did not say what would be considered normal. To address the problem, the inspector general recommended that the hospital perform surgeon peer reviews.

In the case of the contract with USF, the investigation concluded that the workload at Haley was not sufficient to justify a $300,000 cardiovascular services agreement with the university.

According to the report, Haley has entered into contracts with USF to provide cardiovascular surgery services, including pre- and post-surgical evaluations, treatment, and followup since 1995.

Since 1999, however, the hospital has hired staff surgeons, decreasing the workload for USF physicians.

Investigators said that should have resulted in a decrease in the level of services required under the contract with USF, but it didn’t.

“We concluded that the medical center was not receiving the level of services paid for under the contract. We concluded that these contracts were not awarded and administered properly for many years, which resulted in VA paying for services that were not needed and not provided,” the report said.

Investigators said the practice by Haley of paying USF physicians for part-time work, in addition to the money they were getting under the contract, amounted to “an improper supplementation of salary.”

Investigators said records show that the medical center was aware as early as 1996 that it was not receiving – and may not have needed – the level of services paid for under the contract with USF.

“Nonetheless, the contract requirements remained unchanged,” the report said.

In response to the investigation, George Gray, the St. Petersburg-based VA director for the southeast United States, said all three contracts between Haley and USF would be reviewed.

In comments contained in the report, Gray also said Haley had taken a series of steps to correct the problems identified by the inspector general, such as hiring a scheduler to improve operations in the operating room and implementing peer reviews.

In a statement late Thursday, USF spokeswoman Anne DeLotto Baier said USF will cooperate with any review the VA conducts of contracts with USF.

Paul de la Garza can be reached at or 813-226-3432.

[Last modified October 26, 2006, 22:05:37]

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