Marine Jason Simcakoski Died and Wisconsin VA At Fault

VA hospital at fault in Marine veteran's death
Marine Corps Times
By Patricia Kime, Staff writer
August 20, 2015

But investigators found that nearly all the drugs found in the veteran's system could cause sedation and the patient's record "confirmed that all these drugs were prescribed by providers at the facility."

Jason Simcakoski died at the Tomah (Wisconsin) VA Medical Center on Aug. 30. An inspector general's investigation says hospital staff improperly prescribed medication to the Marine veteran.
(Photo: Family photo)

A Veterans Affairs Department investigation into the death of a former Marine at the Tomah, Wisconsin, VA Medical Center found the staff failed to properly prescribe medications and blundered the medical response when the veteran was found unresponsive in his bed.

Jason Simcakoski died Aug. 30, 2014, in the hospital’s short-stay mental health unit from “mixed drug toxicity,” having taken 13 prescribed medications, including several that cause respiratory depression, in a 24-hour period.

According to a VA Inspector General report released Aug. 6, staff psychiatrists had added new medications to Simcakoski's lengthy list of prescriptions in the days preceding his death.
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Veterans testify VA doctors increased meds without treating problem

Wounded Times tried to warn about this and now, well now that CBS says it, it must be true. OK. What took them so long to figure this out?

Veterans testify VA doctors increased meds without treating problem
CBS
By Jim Axelrod, Jennifer Janisch
October 10, 2013

(CBS News) WASHINGTON - A House subcommittee heard testimony Thursday on a problem CBS News exposed last month: Many returning war veterans are overmedicated, with some receiving lethal amounts of pain medication from Veterans Affairs hospitals.

On Capitol Hill, two veterans crippled by debilitating pain described their VA doctors increasing narcotics dosages instead of treating the underlying causes.

"I struggled with years of dependence on opioid therapy that was my only option made available to me for my chronic debilitating back pain," said Justin Minyard.

Minyard, a retired Army special ops interrogator, first hurt his back as a first responder at the Pentagon on 9/11.

"At my worst point, I was taking enough pills daily to treat four terminally ill cancer patients," said Minyard.
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Walter Reed pharmacy sent home wrong medication

Walter Reed clinic gives Christiane Wiggins heart medicine instead of vitamin
Brandie Piper
KSDK
May 8, 2013

KING GEORGE, VA (WUSA) - U.S. Senator from Virginia is demanding answers after another medical mix-up at Walter Reed Military Medical Center.

Mark Warner wants to know why a Virginia woman was sent home with a powerful and potentially deadly heart drug, instead of the vitamin shots she was supposed to get.

Christiane Wiggins was shaken when her son opened the package of medicine dispensed from a Walter Reed clinic at Dahlgren Navy Base.

"My brain went, I was sick to my stomach," she said.

"It was labeled B-12 on the bag, labeled as B-12 on the package insert, on the printed label on the bottle," said her son, Chris Wiggins.
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VA reviewing medications at Lincoln Community Based Outpatient Clinic

Healthcare Inspection
Review of a Patient’s Medication Management
Lincoln Community Based Outpatient Clinic Lincoln, Nebraska
August 10, 2012

Executive Summary
The VA Office of Inspector General Office of Healthcare Inspections conducted a review of the medication management provided for a patient who received health care and prescriptions at the Lincoln Community Based Outpatient Clinic (CBOC) of the VA Nebraska-Western Iowa Healthcare System. The patient died unexpectedly, and a medical examiner determined the patient’s cause of death was accidental multidrug toxicity. The purpose of this review was to determine if the patient received appropriate medication management.

The patient had a complex medical and mental health history, which included acute and chronic pain. He was well known to CBOC staff; from 2004 through February 2012, he received MH, primary care, and/or pharmacy services at least every 30 days at the CBOC.

A psychiatrist treated the patient and prescribed medications to address his mental health needs. A physician assistant treated the patient and prescribed medications to address his other acute and chronic conditions. CBOC providers prescribed a number of medications that had the potential for adverse interactions. The patient’s medication regimen remained essentially the same for several years prior to his death. Providers performed medication reconciliations, (reviews of active VA and non-VA medications), and monitored the patient’s compliance with his medication regimen.

Providers, pharmacists, and pharmacy software identified potential adverse medication interactions (low blood pressure, elevated potassium, and electrocardiogram abnormalities). Providers monitored these potential adverse medication interactions by annual blood chemistries, drug levels, and electrocardiograms. Mental Health providers conducted assessments at an appropriate frequency, referred the patient to pain management clinic services, and monitored his prescribed opioid use closely. CBOC providers managed the patient’s medication management appropriately. We made no recommendations. read report here

Buying medications outside of contracts was just an effort to help veterans

VA: Buying medications outside of contracts was just an effort to help veterans

By Steve Vogel, Published: February 1

The Department of Veterans Affairs’ purchase of $1.2 billion in pharmaceuticals since 2004 in violation of federal law and regulations was the result of “a team failure” at the department, VA Deputy Secretary W. Scott Gould told the House Veterans Affairs Committee on Wednesday.

Gould and a panel of other VA officials testified that the actions did not represent criminal wrongdoing or fraud. Instead, they described the violations as misguided efforts to ensure that veterans could get drugs unavailable through the normal contracting process.

“It broke down to such an extent that the wrong way became the ‘way we’ve always done it,’ ” Gould testified.

Committee members excoriated the department for its conduct and vowed to continue investigating the matter.

“What VA has been doing is not mere bureaucratic oversight,” said Rep. Jeff Miller (R-Fla.), chairman of the committee. “It is illegal, with serious potential ramifications for veterans.”
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Veterans exposed to incorrect drug doses

Just keeps getting worse and worse for our veterans at the same time they tell us they are finally getting things right.

Veterans exposed to incorrect drug doses
San Diego Union Tribune -
San Diego,CA,USA
By HOPE YEN, The Associated Press 11:37 a.m. January 14, 2009

WASHINGTON — The top Republican on the House Veterans Affairs Committee demanded Wednesday that the VA explain how it allowed software glitches to put the medical care of patients at its health centers nationwide at risk.
"I am deeply concerned about the consequences on patient care that could have resulted from this 'software glitch' and that mistakes were not disclosed to patients who were directly affected," said Rep. Steve Buyer, R-Ind. "I have asked VA for a forensic analysis of all pertinent records to determine if any veterans were harmed, and I would like to know who was responsible for the testing and authorized the release of the new application."
Patients at VA health centers were given incorrect doses of drugs, had needed treatments delayed and may have been exposed to other medical errors due to the glitches that showed faulty displays of their electronic health records, according to internal documents obtained by The Associated Press under the Freedom of Information Act.
The glitches, which began in August and lingered until last month, were not disclosed to patients by the VA even though they sometimes involved prolonged infusions for drugs such as blood-thinning heparin, which can be life-threatening in excessive doses.
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