OSC Seal

U.S. Office of Special Counsel

1730 M Street, N.W., Suite 300

Washington, D.C. 20036-4505


(202) 653-7984  

    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 allegations.

    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.