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Publication

The Systemic Failures and Preventable Tragedies at the Tomah VA Medical Center

Senate Committee on Homeland Security and Governmental Affairs
Abstract
The Senate Committee of Homeland Security and Governmental Affairs issued a Majority Staff report investigating possible systematic issues and avoidable harms within the Tomah, Wisconsin VA medical facility. The report focused on possible over-prescription of opioids, fostering a culture of silence towards whistleblowers, and problematic oversight that could lead to preventable problems. The report found that many of these things did occur, and they were the result of institutional and oversight failures from executive leadership.
Date
2016-05-31
Document Type
Senate Majority Staff Report
Serial Number
Document Length
376 pages
Congress
114
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Files
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2016-05-31_R-Systemic_Failures_at_the_Tomah_VA_Medical_Center-114C.pdf
Adobe PDF, 19.47 MB
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Tomah_VA_Source_Material.pdf
Adobe PDF, 350.05 MB
URI
https://hdl.handle.net/20.500.14300/317
Relation
DOI
Keywords
Staff Reports
PAP Major Code
3: Health
PAP Minor Code
324: Medical Liability, Fraud and Abuse
Related Hearings
Press Releases and Contextual Information
Collections
Senate Oversight Committee