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A veteran death shows a VA facility is failing on many levels



The Department of Veterans Affairs is well aware that veterans suffer from mental health issues at an alarming rate. It is also well known that the healthcare system keeps showing itself inadequate, which is the biggest proof that single payer and government healthcare are both untenable. The Central Ohio VA medical facilities were found to probably have failed a veteran, who committed suicide and has put many others at risk because their medical records system is not being monitored correctly.

Warning and Statement

To start with, this article is not meant to be clickbait but to educate. I am a veteran and at one time was suicidal. From time to time, I still have those thoughts. This is to educate people about the garbage that veterans have to deal with every single day. It is idiotic that they continuously fail men and women who got hurt for this nation. They fail those who are willing to defend this nation, along with willing to die for this nation. This needs to be fixed.

Veteran Death

Here, via the VA OIG, is what happened that led to the death of a veteran.

The VA Office of Inspector General (OIG) reviewed concerns related to the care of a patient who died by accidental overdose approximately seven weeks after a missed appointment at the VA Central Ohio Healthcare System in Columbus (facility). The OIG evaluated staff’s failure to conduct minimum scheduling efforts due to an error in new electronic health record (EHR) functioning. The OIG reviewed the adequacy of mental health evaluations of the patient, supervision of a psychologist, caring communications management, and an internal review of the patient’s care.

The OIG found that due to the EHR system error, the patient’s missed appointment was not routed to a queue to prompt rescheduling efforts. The OIG determined that, unlike established care standards, for sites using the new EHR, VHA required fewer patient contact attempts following missed mental health appointments.

The OIG found that the nurse practitioner did not evaluate a request from the patient to restart medication nor obtain a comprehensive mental health history. The psychologist did not thoroughly evaluate or address the patient’s depression and failed to reconcile critical clinical information. The OIG would have expected a supervisory psychologist to identify concerns about the patient’s depression, substance use relapse risk, and suicidal behavior, and ensure follow-up regarding the medication request.

The OIG found that staff failed to send the patient caring communications after high risk for suicide patient record flag inactivation. Facility leaders did not communicate a root cause analysis Lesson Learned to staff as expected.

Further Issues Found

Here, via another OIG report, are more issues found at the same center.

The VA Office of Inspector General (OIG) conducted an inspection at the VA Central Ohio Healthcare System (facility) in Columbus to review an allegation that implementation of the new electronic health record (EHR) led to a prescription backlog. While reviewing the allegation, the OIG determined facility leaders took timely and sustainable steps to manage the issue. However, the OIG identified other facility and national pharmacy-related patient safety issues.

The OIG found implementation of the new EHR at the facility, despite known pharmacy-related patient safety and usability issues, contributed to ongoing patient safety risks and usability challenges at the facility. The new EHR contributed to pharmacy-related patient safety issues nationally as a software coding error resulted in inaccurate medication and allergy information transmission from new EHR sites to legacy EHR sites. Affected patients were not notified of their risk of harm and the OIG remains concerned for their safety. The OIG learned VHA communicated recommendations to providers to mitigate the risk of harm to affected patients; however, the recommendations were non-sustainable.

Additionally, the new EHR's operational inefficiencies required increased clinical pharmacist staffing and development of workarounds and educational materials to complete pharmacy processes. The inefficiencies also led to pharmacy staff burnout, job dissatisfaction, and decreased morale.

Solution

There is one solution, get rid of the dead weight and politics. Fix the problems, starting with any money to be given to the criminals that cross the border or those on welfare that should be working needs to go to the VA. These medical centers need to be maintained to the quality that veterans deserve, not as forgotten holes to hide these men and women. It is past time we end this garbage.

I have no words. I am well aware that this article will not get the views it deserves. Veterans are dying by their own hands because they need to stand between the citizens of this nation and the horrors of the world. People use them for political purposes, while we all just want to be seen. Quit thanking us and show being thankful by putting people into office who will keep the promise made by Lincoln.

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