Doctors at the U.S. Department of Veterans Affairs medical center in Tomah, Wisconsin, engaged in unsafe clinical practices while the hospital leadership created a culture of fear that compromised care and harmed the staff, according to a preliminary report released today.
The report, written by the VA’s interim undersecretary for health, Carolyn Clancy, is based on an internal probe the agency announced in January after The Center for Investigative Reporting revealed that runaway opiate prescriptions had caused some veterans to call the hospital “Candy Land.”
Last August, a 35-year-old Marine Corps veteran died of an overdose while in the hospital’s psychiatric ward.
The VA’s internal investigation confirmed many of CIR’s findings. It found that Tomah VA patients were 2.5 times more likely than the national average to be prescribed heavy doses of opiates, and that narcotic painkillers frequently were issued in combination with tranquilizers – a combination that can cause a person to stop breathing.
The preliminary report describes multiple instances of “patient harm at least partially attributable to prescribing practices” at the hospital and says that veterans’ medications were not changed even “in the face of aberrant behavior.”
Clancy said the investigation would continue. Tomah VA chief of staff David Houlihan, whom veterans nicknamed the “Candy Man,” has been placed on administrative leave while the VA’s internal investigation continues, as has Deborah Frasher, a nurse practitioner who worked closely with Houlihan.
In addition to the agency’s internal review, the Tomah hospital also is being investigated by the VA’s inspector general, two congressional committees and the Drug Enforcement Administration, while the Wisconsin Department of Safety and Professional Services has opened an inquiry into Houlihan, Frasher and pharmacist Margaret Hyde at the Tomah VA, which could cause them to lose their medical licenses.