U.S. OFFICE OF SPECIAL COUNSEL TRANSMITS REPORT OF INVESTIGATION IN RESPONSE TO
WHISTLEBLOWER’S ALLEGATIONS OF INADEQUATE ANESTHESIA CARE AT CARL T.
HAYDEN VETERANS AFFAIRS MEDICAL CENTER, PHOENIX, ARIZONA
FOR IMMEDIATE RELEASE - 4/13/00
CONTACT: JANE MCFARLAND
The U.S. Office of Special Counsel (OSC) today
transmitted to President Clinton and the Congress, an investigative report
from the Department of Veterans Affairs (VA), into whistleblower allegations
of a substantial and specific danger to public health and safety at the Carl
T. Hayden Veterans Affairs Medical Center (VAMC), Phoenix, Arizona.
The VA investigation was triggered by a disclosure made
to the OSC by Winston Liao, M.D., a physician anesthesiologist at the VAMC.
Dr. Liao alleged that he observed an extremely high rate of complications
occurring in patients under the care of a particular Nurse Anesthetist. He
alleged that this individual falsified medical records by pre-recording
patient’s vital signs during the administration of anesthesia, and that he
left patients unattended during procedures. Dr. Liao claimed that the Nurse
Anesthetist’s behavior caused at least four patient deaths, and resulted
in the collapse of at least eight patients after surgery. Dr. Liao also
asserted that the Nurse Anesthetist had been involved in nearly 200 cases of
serious injury or death as a result of his incompetence.
The OSC found that Dr. Liao’s disclosures demonstrated
a substantial likelihood of a specific danger to public health and safety,
and forwarded the allegations to the VA, directing it to conduct an
investigation and provide a written report. The OSC sought written
clarification and further investigation from the VA on several occasions,
after receipt of the initial written report. The VA subsequently issued a
final report addressing the allegations, and a supplemental report
confirming the actions the VA has taken in response to Dr. Liao’s
The VA report partially substantiated Dr. Liao’s
allegations. It found that the Nurse Anesthetist provided substandard
anesthesia care in six of 14 cases over a period extending from 1993 to
1999. The report confirmed that the subject Nurse Anesthetist had incidents
in the post-anesthesia care unit in numbers greater than the other five
nurse anesthetists did. In six patients, according to the VA report,
premature endotracheal extubation at the end of anesthesia appeared to be
the primary problem. Of the 14 patients studied, three died. Despite its
findings that several patients received substandard care, the VA report
concluded that there was no evidence that the Nurse Anesthetist’s behavior
caused these deaths. The report did confirm that the Nurse Anesthetist had
behavioral issues, and was heard to speak about veteran patients in a
deprecating, insulting manner.
On a broader scale, the VA report found that the VAMC
lacked a plan and process to measure and assess data regarding anesthesia
quality issues during the period from 1993 to 1999. The report also found
that senior VAMC officials did not communicate serious concerns related to
anesthesia and surgery upwards. The report found numerous weaknesses in the
infrastructure supporting the surgical and anesthesia programs. Finally, the
report found that officials at the VAMC violated the law by failing to
provide proficiency rating for the Nurse Anesthetist since January 1997.
Based on the findings of the investigation, the VA
represented that it has taken several measures to address the serious
patient care issues raised by Dr. Liao: (1) standardized extubation
guidelines are in place, and no further system-wide action is required; (2)
the subject Nurse Anesthetist remains under appropriate supervision and
performance monitoring by the Acting Chief, Anesthesia Section. The subject
received a proficiency rating of highly satisfactory in January 2000; (3) a
supervising Certified Registered Nurse Anesthetist has been appointed to
assist in monitoring and to address learning needs of the group; (4)
anesthesia staff members have completed an Airway Study, focusing on
reintubation in the immediate post-operative period; (5) criteria for
endotracheal extubation were developed and implemented by anesthesia staff
at the Medical Center in September 1999; and (6) systematic data collection
on performance measures in anesthesia began in June 1999 and continues.
The Special Counsel has determined, pursuant to 5 U.S.C.
§ 1213(e)(2), that the findings in the agency’s report contain all of the
information required by statute, and that the findings appear reasonable
except to the extent that the VA has not committed to take specific
disciplinary or other appropriate action against individuals found to have
provided substandard care to patients. The Special Counsel has recommended
that the VA be encouraged to reexamine any policy or procedures that would
permit or force the retention of such employees.
Among its other functions, the Office of Special Counsel
provides federal employees with a secure channel for blowing the whistle on
violations of law, rule or regulation, gross mismanagement or waste of
funds, an abuse of authority, or a substantial and specific danger to public
health and safety. The OSC is empowered to require agencies to conduct
investigations whenever it finds a substantial likelihood that a federal
employee’s disclosures demonstrate the existence of one of these
conditions, and to report back to the OSC its findings along with any
corrective action taken. After the OSC reviews the report to insure that it
contains the necessary information and that its findings appear reasonable,
the OSC transmits the report to the President and the Congress for further
action, if appropriate.
Copies of the VA report, Dr. Liao’s comments, and
Special Counsel Elaine Kaplan’s transmittal letter can be obtained by
contacting the OSC.