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Diane Publishing Books
Systemic Failures and Preventable Tragedies at the Tomah VA Medical Center
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Ron Johnson (ed)
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 ńˇýCandy LandńˇŁ 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 Generalńˇ╗s (VA OIGńˇ╗s) 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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