Clinical Review: Unsafe clinical practices in pain management at Tomah VA

Tomah VA's Chief of Staff Dr. David Houlihan put on administrative leave

The first review of prescription practices is complete at the Tomah VA medical center almost two months after allegations of over-prescribing opiates at the facility first surfaced.

VA Deputy Secretary Sloan Gibson was in Tomah Tuesday to release the results of this initial review as investigations continue into the over-prescribing of opiates at the medical center.

The clinical review was conducted by Interim Under Secretary for Health, Carolyn Clancy. The results paint an alarming picture, giving a sneak peak at what has been happening at the Tomah VA.

After allegations of over-prescribing opiates to patients surfaced in January, a clinical review was ordered.

“I think everyone is aware of the visit of the clinical review team over a month ago,” said Gibson.

For 30 days, a team of nine clinicians assessed opiate prescribing habits, employee interactions and clinical leadership at the Tomah VA.

“The team submitted its report on the 4th of March based on a review of medical records on a sampling on 18 patients,” said Gibson.

The team determined there are unsafe clinical practices at the Tomah VA center in areas of pain management and psychiatric care.

“More specifically, six of the 18 cases revealed patient harm, for example a patient fall, could be partially attributed to prescribing practices,” said Gibson.

The review found the opioid prescriptions at the Tomah VA are actually lower than they are on average across the VA system.

“About 11.5 percent of Tomah patients receiving a prescription for opioids compared to 14.6 percent of patients across the VA,” said Gibson,

However, Tomah patients are 2.5 times more likely to be prescribed higher dosages of opioids.

“There was also a higher incidence of both opioid and benzodiazepines medication in combination than elsewhere, roughly twice than across the department,” said Gibson.

The team of clinicians also found there is a continued culture of fear among employees and it has compromised patient care.

“We can’t have people, front-line employees afraid to raise their hand,” said Gibson.

Based on those findings, Gibson is calling for a more in-depth clinical review .

“That has been commissioned with an outside organization that routinely conducts these kind of reviews for the VA and for the private sector,” said Gibson.

Gibson said these results are being taken seriously and he is determined to fix the problems.

“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.

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.

A hearing for the congressional investigation into the Tomah VA over-medicating patients will be held at the medical center on March 30. It will give the staff and patients a chance to weigh in on the issue. It’s scheduled to start at one in the afternoon.

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