New GAO Report Reveals Rampant Drug Policy Failures At the VA

Brittany M. Hughes | February 28, 2017
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In the latest chapter of “Why The Department of Veterans Affairs Sucks,” it turns out that some VA medical facilities aren’t actually checking to make sure drugs are being removed and administered correctly by their staff, leading to escalating drug abuse by federal employees and extreme risk to veterans. 

An alarming new report from the Government Accountability Office found multiple VA facilities that consistently failed to hold drug inspections, which are intended to make sure workers are properly dispensing drugs to patients and not, say, playing keepsies with the hydrocodone or popping Vicodin from Pez dispensers.

The GAO stated that of the four clinics in question, “Two of the four did not conduct monthly inspections of controlled substances as required by the Veterans Health Administration (VHA). For example, one facility missed 43 percent of monthly inspections in critical patient care areas and the pharmacy for the period GAO reviewed—January 2015 to February 2016.”


To make matters worse, the GAO added:

Further, inspections that three of the four facilities performed did not include or follow three or more of the nine VHA requirements GAO reviewed. At two of the three facilities, for example, inspectors did not properly verify that controlled substances had been transferred from VA pharmacies to patient care areas; nor did inspectors ensure that all controlled substances on hold for destruction were properly documented.

In its report, the GAO detailed just two recent examples of drug misuse by VA employees, including one employee who infected veteran patients with hepatitis after ​first ​injecting himself with drugs from syringe​s​ and ​refilling ​the dirty needles with saline solution.

In recent years, diversion of controlled substances has occurred at several VA medical facilities. For example, an investigation in 2012 found that a former health care employee at the VA medical facility located in Baltimore, Maryland had been diverting the opioid fentanyl—an anesthetic used for patients undergoing surgical procedures—for his own use. The employee was injecting himself with syringes of fentanyl intended for patients undergoing surgery and then refilling the empty syringes with saline solution. Instead of receiving the prescribed dose of fentanyl with its intended anesthetic effect, patients received saline solution that was tainted with the Hepatitis C virus carried by the employee.

Another investigation in 2012 found that an emergency room nurse at a VA medical facility was injecting herself with syringes of hydromorphone, an opioid pain reliever, intended for patients. After identifying discrepancies in the amounts of hydromorphone the nurse documented as having administered to patients, VA officials accused the nurse of diversion. Eventually, the nurse confessed to having diverted hydromorphone for approximately six months.

Apparently, this isn’t the first time the GAO has brought these policy discrepancies to the VA’s attention, pointing to similar reports they issued back in 2009 and again in 2014. The in-depth report adds the VA clinics in question may have missed their inspections due to a host of reasons, including a lack of training, a staffing deficiency, and sub-par written policies.

Additionally, it turns out that nothing actually happens when a clinic misses a required required monthly inspection.

Then again, another GAO report issued in January revealed the VA has no clue how many hours its employees spend working on union time versus actually helping veterans, so losing track of its own drugs seems pretty standard.