‘Unsafe clinical practices’ at Tomah VA, review team finds

Clinical review team also found ‘apparent culture of fear at the facility'

A clinical review team from the VHA found “unsafe clinical practices” and “an apparent culture of fear” at the Tomah VA Medical Center.

Dr. Carolyn Clancy, interim secretary for health for the Department of Veterans Affairs, announced the results from the comprehensive review of medication prescription practices on Tuesday memo.

Based on a review of computerized medical records of 18 patients the team of nine clinicians and other subject matter experts from across the VHA found unsafe clinical practices at the Tomah VA in areas such as pain management and psychiatric care.

“More specifically, six of the 18 cases revealed that patient harm (exampled of falls) that could be at least partially attributable to prescribing practices (multiple CNS depressants and/or high dose opioids); nine of 18 lacked evidence of changing the treatment plan in the face of aberrant behaviors; and twelve of 18 demonstrated extensive use of opioids and benxodiazepine,” Clancy stated in a memo to the secretary of the Department of Veteran Affairs.

Clancy said the review team also found an “apparent culture of fear at the facility compromised patient care and impacted staff satisfaction and morale.”

On Tuesday, VA Deputy Secretary Sloan Gibson visited the Tomah VA Medical Center to meet with employees, facility leadership and stakeholders. During an afternoon news conference, Gibson spoke about the findings of the review.

“Among the findings in that is a strong recommendation, that has been pursued, to commission a broader and more in-depth clinical review,” Gibson said. “That has been commissioned with an outside organization that routinely conducts these kind of reviews for the VA and for the private sector.”

“My commitment is, we will follow the evidence where ever it leads, no one is immune, no topic is immune, okay, no sacred cows,” said Gibson.

Congressman Sean Duffy said, “I’m glad the VA is sending top level officials to meet with our community in Tomah, but we must go beyond polite conversations. We must continue to push for increased transparency — and accountability — from the Tomah VA, and the VA as a whole. The families of the deceased, and this community, deserve answers. That is what we will seek to get at the hearing on March 30th.”

U.S. Senator Tammy Baldwin released the following statement: “These initial findings substantiate the troubling concerns my office has heard from current and former employees and patients at the Tomah VA. As the investigation builds on this troubling evidence and moves forward, it is critical that it be conducted in a detailed, thorough, and transparent manner. I also believe that the final result of this investigation must include appropriate corrective action that brings accountability to those responsible for the problems at the Tomah VA and puts in place solutions to prevent these problems and tragedies from ever happening again. My goal is to ensure the VA delivers the timely and highest-quality care our Wisconsin veterans have earned.”

When the investigation started, the two individuals at the center of it, including the Tomah VA’s Chief of Staff Dr. David Houlihan, were moved to administration duties. However, with these findings, Gibson has put them on administrative leave. He said it is not a disciplinary action but a precaution to make sure they don’t interfere with the ongoing investigations in any way.