VAOIG Inspection of Northern Indiana VA Health Care System Fort Wayne and Marion, Indiana

Healthcare Inspection Alleged Mismanagement of Resources and Patient Safety Issues VA Northern Indiana Health Care System Fort Wayne and Marion, Indiana 03/02/2010. The purpose of this review was to determine the validity of allegations regarding instrumentation problems with Operating Room (OR) sets and peel packages; reusable medical equipment issues; Supply, Processing, and Distribution (SPD) stocking and dating of supplies; pharmacy stocking of OR, Post Anesthesia Care Unit, Endoscopy Unit (OR, PACU, EU) medications; and management issues. We substantiated that: (a) OR sets and peel packages were returned from the Marion campus’ SPD incorrectly as previously noted by a number of external reviewers, (b) SPD technicians were unable to identify instruments, and previous recommendations to take pictures of instruments sets were not followed, (c) an ankle fusion procedure requiring an implant was canceled and rescheduled three times, (d) specific medication was ordered but not present 7 days later so Pharmacy borrowed the medication from a local hospital, and (e) the OR, PACU, EU nurse manager provides coverage in other areas of the hospital and was unavailable to guide staff. We identified other environment and maintenance issues at the Fort Wayne campus that required management attention. We recommended that actions be taken to correct OR and SPD instrumentation problems, ensure that all SPD supplies and equipment are properly managed and ready for patient care, review the OR, PACU, EU nurse manager supervisory roles and responsibilities, and correct environmental and maintenance concerns. VAOIG