Empower Wisconsin | Sept. 25, 2019
By M.D. Kittle
Madison — Internal emails suggest the Tomah Veterans Affairs hospital — once described as “Candy Land” for its deadly opioid prescription policies — might have prevented the December 17, 2017 incident that spiked pharmacy temperatures as high as 97 degrees, damaging prescriptions and leaving staff scrambling to find replacement drugs.
The troubled Tomah VA Medical Center had experienced previous problems with a malfunctioning climate-control system at its outpatient pharmacy before the major meltdown in late 2017, according to a Freedom of Information Act request obtained by Empower Wisconsin.
“We had a similar problem this summer,” wrote an unidentified Tomah VA staff member in an email, dated Dec. 18, 2017.
Two days later, after the fog began to lift on the system meltdown, a Tomah official described the temperature spike in the outpatient pharmacy as a “little incident.” That characterization was misleading at best.
The emails obtained in the FOIA underscore the concern from pharmacy staff members, and the apparent lack of policy in dealing with the possibility of a temperature surge — despite the fact that the pharmacy had experienced a “similar problem” months before.
“Just wondering if anyone knows of a site or information available for medications that may have been overheated due to a faulty thermostat in our pharmacy over the week-end,” an unidentified Tomah VA employee wrote. “Our alarm system went off, but no one responded to it so the pharmacy got up to 97 degrees. Does anyone have a policy that we need to follow in this type of situation? From what we are seeing looking at drug inserts we could be disposing a lot of medication and I would hate to waste any more than necessary.”
The pharmacy did end up tossing a lot of medicine, erring on the “side of caution,” according to a follow-up email.
“(T)he medication stock,” about $60,000 worth, “was completely reordered,” a pharmacy official wrote. Any “emergent” medication needs were met by using “inpatient pharmacy stock.” It took a couple of days, however, to fill the outpatient’s medicine cabinets.
VA officials were less than forthcoming when first asked about the malfunction. They heavily redacted FOIA-requested documents or refused to release information to MacIver News Service, which originally investigated the malfunction.
In February, after months of VA foot-dragging, Cause of Action, a Washington, D.C.-based government watchdog, filed a lawsuit in federal court alleging the agency had failed to properly respond to the Freedom of Information Act request the organization had filed more than a year before.
Legal problems are nothing new for the Tomah VA Medical Center, which was the subject of multiple federal investigations after a Marine veteran died of a prescription drug overdose in 2014 while in the hospital’s Short Stay Mental Health Recovery Unit.
A 359-page report from the Senate Homeland Security and Governmental Affairs Committee, chaired by U.S. Sen. Ron Johnson (R-Oshkosh), was particularly critical of the VA inspector general for failing to serve as watchdog, or even to listen to other watchdogs, as veterans languished in a failed health care system.
“Perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC was the VA Office of Inspector General’s two-year health care inspection of the facility,” the report stated.