Healthcare Inspection – Oversight Review of Ophthalmology Adverse Drug Events, VA Greater Los Angeles Healthcare System, Los Angeles, CA

OIG conducted an oversight inspection to review actions taken to address and respond to adverse drug events (ADEs) that led to blindness in the treated eye of five patients at the VA Greater Los Angeles Healthcare System (the facility). We determined that VISN and facility leadership complied with VHA policy in taking immediate actions in response to these ADEs. They appropriately notified the patients and contacted the FDA and VHA leaders while ascertaining the cause of the ADEs. The facility’s action of disclosing to the patients that a medication error occurred is consistent with VA’s commitment to transparency. In addition, the facility convened an administrative board of inquiry (ABI) to address other administrative and patient safety issues. We recommended that the Facility Director ensure that the recommendations from the local and external reviews are implemented and monitored, that the ABI is completed in a timely manner, and that corrective actions in response to the ABI are taken if indicated. Management agreed with the findings and recommendation and provided an acceptable action plan.