BUFFALO, N.Y. (WIVB) – A scathing letter to President Barack Obama is raising new concerns about care at Buffalo’s VA hospital.
The Office of the Medical Inspector sent the president a letter saying teams were able to validate claims that workers at the hospital did not always comply with VA sterilization standards for wearing protective equipment.
Inspectors also found that workers occasionally failed to place indicator strips in surgical trays and mislabeled sterile instruments. Despite this, the office says it does not believe this affected patient safety.
US Special Counsel Carolyn Lerner accused the VA of failing to use the correct and verified information from whistle blowers at the VA hospital in Buffalo and several others, including Fort Collins, Colorado and Brockton, Massachusetts
“It’s impossible, I think, to conclude that no one was harmed when there were such long delays in getting medical care,” said Carolyn Lerner. “Often we would send reports back to the VA and sort of say in a very nice way, are you kidding us here?”
The US Special Counsel recommended the VA investigate how it handles these valid whistleblower complaints. The VA’s acting secretary Sloan Gibson immediately agreed and promised an internal review.
News 4 spoke with Lisa Magin, a former employee of the Buffalo VA who says she can recall being ignored when she spoke up, and was later fired for it.
“I couldn’t get anyone to listen to me, or take anything I was saying seriously.”
Magin was a medical supply technician in the Buffalo medical center’s Sterile Processing Service, the department responsible for cleaning and sterilizing medical tools between uses.
When she saw her co-workers taking shortcuts or skipping basic work rules, Magin said she reported those discrepancies to her supervisor, but the complaints were dismissed.
“[They would] waive me off, tell me that my work standards were too high. Not to slack off, but to just back off and relax.”
Eventually, Magin’s co-workers turned against her, which she says posed a hostile work environment for her, taking a toll mentally and emotionally. Magin took a one-year unpaid leave of absence, then was ordered to return, against medical advice.
Magin says she listened to her doctor and refused to return, so she was fired in 2012.
“They just made it seem like I was the problem, and all I wanted to do was make sure that we were doing the right things.”
Congressman Chris Collins is calling on the Buffalo VA to fire Larry McCurdy, the Chief of Sterile Processing Services at the Buffalo VA. Collins says he is ultimately to blame for these latest reported shortfalls.
“They are examples of the same lack of attention, lack of proper procedures, lack of best practices,” said Collins.
Rep. Brian Higgins also said VA workers who do blow the whistle need to be taken seriously.
“Employees that work at the VA, not only in Buffalo but throughout the country, need to be encouraged that when they see something they need to say something. That is the only way you build in improvements into the VA system.”
Kathryn VarKonda, Performance Manager at the Buffalo VA insisted they took the whistleblower charges seriously, eventually acted on them, and on monthly basis, a committee assesses errors in sterile processing, and takes action to correct them.
VarKonda said, “Was it a process issue, or was it a people issue? I always like to say we are dealing with human beings here. I mean, have any of us ever not made a mistake? People make mistakes.”
VarKonda also revealed, managers and line staff have been re-assigned in the wake of the whistleblower controversy. Rep. Higgins is calling on Veterans Affairs to take stronger action against managers who have retaliated against whistleblowers, or dismissed their claims.
Magin is now fighting to get her job back, claiming her federal whistleblower protections were violated. Congress and President Obama enhanced protections for government whistleblowers in 2012.
Collins adds that it’s unclear if any of this is still happening inside the Buffalo VA. He says it’s obvious the hospital needs to be working on best practices and procedures.
“They should be benchmarking with the Catholic [Health] System, with ECMC and Kaleida,” Collins insisted. “Instead, the arrogance of the VA is they always know best. Well, I think we all know now, they don’t know best. That arrogance and the bureaucracy is what’s not servicing our veterans well and clearly they deserve better.”
In January of last year, some inpatients being treated for diabetes at the Buffalo facility were told the insulin pen used on them may have been used on other patients as well.
“There is a very small chance that that would expose one veteran to Hepatitis C, Hepatitis B, and HIV virus,” Dr. Donald A. McDonald, Chief of Medicine, said during an interview with Rich Newberg in 2013.
The Office of the Medical Inspector does not believe these latest confirmed claims in Buffalo affected patient safety.
A VA spokeswoman released this statement to News 4:
“When any concern is brought forward about patient safety, VA Western New York Healthcare System takes it very seriously, looking in to facts and taking corrective action if necessary.
Regarding continuous improvement, training and our quality management programs, employees are encouraged to bring issues forward to improve systems to ensure Veterans are receiving the best care possible. Consistent review of data and trends to identify areas of potential improvement are an integral part of VA’s patient safety program.
Any adverse incident that potentially affects one Veteran within our care is one too many. When an incident occurs we at VAWNYHCS aggressively identify, correct and work to prevent additional risks.
A review was requested by leadership from outside Sterilization Processing Service experts to improve processes and systems. We cooperate with the Office of Special Counsel, the Inspector General or any other investigative agency to understand what happened, prevent similar incidents in the future, hold those responsible accountable consistent with due process under the law, and share lessons learned across VA’s system.
As Acting Secretary Gibson recently stated, we must protect whistleblowers and create workplace environments that enable full participation of employees VA WNYHCS has zero tolerance for intimidation or retaliation – not just against whistleblowers, but against any employee who raises a hand to identify a problem, make a suggestion, or report what may be a violation in law, policy, or our core values – is absolutely unacceptable.”