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Delays in cancer treatment consultations may have played a role in the deaths of 23 veterans and compromised the health of 53 others, according to an internal review released this week by the Veterans Affairs Department.
VA officials blamed the problem on cluttered consultation computer systems, used by physicians for a host of tasks including urgent medical needs and minor bookkeeping efforts.
They’re promising an overhaul of how the network is used, and offering apologies to patients hurt by the mistakes.
“We had a system that was plagued with noise,” said Dr. Thomas Lynch, VA’s assistant deputy undersecretary of health for clinical operations and management, who oversaw the review. “That made it impossible to get a handle on where delays were developing and fix the process.”
Lawmakers have pressed the department on preventable deaths for months, charging officials aren’t doing enough to ensure patient safety. The House Veterans Affairs Committee has planned a Wednesday hearing on the issue.
VA officials said they’ve been reviewing the consultation request process for months, and conceded that their ongoing investigation could turn up additional cases.
The 76 veterans already identified as missing additional care are primarily gastrointestinal cancer patients, awaiting endoscopies and other tests. In all of the cases, patients waited for more than two months after physicians ordered follow-up tests or consultations.
The review covers more than 250 million consultations ordered across the VA health system over the last 15 years. The 76 missed consults are among several million “high-interest” cases, and mostly occurred since 2010, although the department did not give specifics.
Lynch said researchers found that VA physicians have been using the electronic consult management system — designed to schedule consultation appointments — as a catch-all for patient care, including reserving spots in hospital transports and sending messages between doctors.
Officials are working to reprioritize medical requests and separate out administrative issues, to ensure that the volume of requests doesn’t again overwhelm immediate health needs.
In a statement, House Veterans Affairs Committee Chairman Jeff Miller, R-Fla., called that a positive first step but not enough to correct the “heartbreaking” mistakes.
“In addition to swiftly putting in place reforms to ensure this never happens again, it is incumbent upon VA to reveal precisely when these deaths and injuries occurred and whether any VA employees who may have allowed veterans to fall through the cracks have been held accountable,” he said.
“Unfortunately, we haven’t seen any evidence so far indicating that preventable deaths at VA facilities result in serious discipline for the employees responsible.”