Deficiencies in Facility Leaders’ Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Michael E. DeBakey VA Medical Center (facility) in Houston, Texas, to evaluate Veterans Integrated Service Network (VISN) and facility leaders’ response to critical surgical events from 2018 through 2021 and assess actions to prevent reoccurrence. The facility reported eight critical surgical events during this time frame—five wrong-site surgeries and three instances of retained surgical items. The OIG found that facility leaders took progressive actions including peer reviews, counseling, a focused professional practice evaluation (FPPE) for cause, and termination to address a provider responsible for three wrong-site surgeries. However, the OIG identified deficiencies with the implementation and quality of the FPPE for cause, and in reporting the provider to state licensing boards (SLBs) and the national practitioner data bank (NPDB). Facility leaders ensured a root cause analysis (RCA) was generated for each critical surgical event and that Surgery Service leaders implemented additional actions to improve processes. However, the OIG identified deficiencies with some RCAs related to timeliness and subsequent action plans. The OIG determined that three critical surgical events may have been prevented in the absence of the RCA deficiencies. Facility leaders and staff could not explain the reasons for the deficiencies in the RCAs. The OIG determined VISN leaders provided oversight and consultation to facility leaders regarding critical surgical events. VISN leaders provided consultation and recommendations to facility leaders for managing the provider, and conducted annual reviews of the facility’s RCA process, identified deficiencies, and alerted facility leaders to areas in need of improvement. The OIG made three recommendations to the Facility Director related to conducting and documenting FPPEs for cause, reporting providers to SLBs and the NPDB, and completing RCAs and subsequent action plans.