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

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By Ron Johnson (ed)
Year: 2016
Pages: 376
Binding Paperback
ISBN 978-1-4578-6447-6

Product Code: 1457864479

The report of an investigation of the systemic failures across the executive branch that led to preventable tragedies of the Veterans Affairs Medical Center in Tomah, WI (Tomah VAMC) -- the veteran deaths, abuse of authority, and whistleblower retaliation. The Tomah VAMC became known as Candy Land for its easy access to prescription medications. Allegations of drug diversion, opiod over-prescription, retaliation, and mismanagement festered. As a result, veterans died. Contents of this report: The scope of the investigation; missed opportunities to prevent the tragedies at Tomah; The Veterans Affairs Office of Inspector Generals (VA OIGs) health care inspection of the Tomah VAMC; whistleblower retaliation and a culture of fear at the Tomah VAMC; attempts at stonewalling the investigation; increased accountability since the investigation; recommendations. Figures. This is a print on demand report.

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