Last February medical lab technicians at the VA’s American Lake hospital in Lakewood flagged a compromised batch of blood samples because it had been frozen and thawed one too many times.
The blood came from 18 patients scheduled to be tested for hepatitis C. The VA’s mandatory protocol required that the samples be thrown out and the veterans rescheduled for new draws to ensure more accurate results.
Rather than follow those guidelines, however, the lab supervisor chose to refreeze the samples and test them anyway, according to an internal incident report.
Less than a month later, technicians spotted the same error in another batch of 21 blood samples headed for hepatitis C testing. Once again, the lab processed the samples even though a technician noted them as damaged, according to incident reports.
An American Lake technician, Mimi Grace Gelvezon, says the two errors in a span of four weeks reflect a persistent problem of mistakes at the lab that risks endangering patient safety and worsens delays at a busy facility.
The errors followed the January publication of a VA Office of Inspector General report that documented an instance of a mislabeled blood sample that was not reported to hospital administrators until Gelvezon drew attention to it.
The Seattle Times and The News Tribune have obtained numerous incident reports dating back as far as 2010 that describe the types of problems Gelvezon says has dogged the laboratory.
This year alone, some 20 incident reports written by four technicians detail errors in labeling patient test samples as well as delays in processing tests.
VA Puget Sound officials say patient safety is not being compromised at the laboratory.
Though the VA protocol called for throwing out the blood samples scheduled for hepatitis C testing, the lab manager chose to proceed with the tests after researching medical literature that said the samples could be viable for several thaws, according to Chad Hutson, a VA Puget Sound spokesman.
Overall, Hutson says the types of the errors Gelvezon notes reflect normal mistakes that occur in all medical testing labs.
“The error rates for the lab are below the national averages across the country. That’s all labs, not just VA labs,” Hutson said
The American Lake lab does have a couple areas in which it is not meeting performance standards, according to Hutson. Employee morale has declined over the past three years. The busy lab also has experienced problems caring for patients in a timely manner as it tries to keep pace with an increasing number of patients using the hospital.
“We are experiencing some significant wait times,” he said. “We’re working very hard to fix that because we know this should be an in-and-out service.”
Agency under strain
The Lakewood lab’s struggles come as the VA in the Puget Sound region — and nationally — strains to provide medical services to expanding numbers of veterans.
In recent months, the agency has been in turmoil because of revelations that officials in other parts of the country covered up extraordinary lengthy wait times for veterans to see doctors. The VA, in an April report, acknowledged that 23 patients died while waiting for care between 2010 and 2012. Since that report, lawmakers and whistleblowers have alleged that VA delays caused far more deaths
These problems led to the resignation of Secretary Eric Shinseki in May, and calls in Congress for wide-ranging reforms of the VA.
Though investigations are continuing, VA Puget Sound officials say there have been no findings of wait time cover-ups in the regional service network.
During the last fiscal year, Puget Sound VA, through a network of hospitals and clinics, served more than 93,600 veterans, about 73 percent more than the system treated before the wars in Iraq and Afghanistan.
To handle the expanding workload, the American Lake laboratory in 2013 extended its hours to serve more patient but it sometimes has to close to catch up on routine work, according to staff emails.
Even with the extended hours, the laboratory sometimes has difficulty keeping up with the patient load.
An incident report from May 14 of this year, notes that “patients were agitated and complaining of long wait times.” On that day, a patient waiting for a blood draw gave up and left because of the backlog, according to the report.
‘Pattern of alarming incidents’
For Gelvezon, patient safety during blood sampling is a serious concern.
When the blood is drawn, regulations call for VA employees to use two separate identifiers — such as a name tag and Social Security number — to ensure they don’t put the wrong patient’s name on the blood sample
But Gelvezon, in documents provided to Sen. Patty Murray last year, said there were numerous incidents when that did not happen. In these documents, she gave an example of a health tech who wrongly identified two blood samples during the week of May 21-25, 2012.
Gelvezon also cited a Sept. 26, 2012 incident involving a veteran who was taking the prescription drug Coumadin, which is used to thin blood and prevent clotting. That veteran was given the wrong test result, but lab staff who knew about the incident on the day it occurred did not report the result right away.
“There has been a pattern of alarming incidents, negligence, inaction and cover-up and lack of integrity on the part of management,” Gelvezon wrote in a Nov. 2 letter to Murray.
After hearing Gelvezon’s claims, the senator requested that they be reviewed by the VA’s Inspector General’s office.
That review did not find a “systemic” problem with the lab that warranted a full-blown investigation. Instead, it published the brief inspection in January and gave an update directly to Murray’s office.
The report focused on the September 2012 instance of a mislabeled blood sample and it cited technical problems with two different medical testing machines.
In a response, the VA said the blood mislabeling report eventually got the attention of top hospital leadership and had been corrected. The VA bought a second printer for the lab, which made it easier for employees to track their labels.
The VA acknowledged the mistake was not reported correctly to a patient safety manager. But the agency said other incidents from that time frame were documented to hospital leadership because “they seemed to point to an individual’s performance issues.”
“This incident was followed up appropriately and resolved by laboratory leadership,” VA Puget Sound officials wrote in response to the IG inspection.
Murray says she is still paying attention to complaints about the laboratory.
In recent months, Gelvezon said the most serious incidents involved the two batches of samples drawn from patients scheduled to be tested for hepatitis C, a liver disease that can be serious if not treated.
Gelvezon said that processing these samples — rather than tossing them out as VA standards dictate — could lead to inaccurate results that had the potential to put the veterans or their loved ones at risk.
“These various mistakes are wasteful of tax dollars, cause delay in patient care and are potentially fatal,” Gelvezon wrote in a May 6 email to senior hospital administrators.
Hutson, the Puget Sound VA spokesman, said the patients whose samples were botched are being tracked.