The James A. Haley VA Hospital is one of the busiest VA facilities in the country, serving thousands of veterans a day.
But the hospital is also one of the top VA hospitals in the country when it comes to reported adverse drug reactions.
One veteran, who says he was given the wrong medication twice, tells the ABC Action News I-Team that things need to change there.
“I'm not gonna go to my grave and not step up and fight for my brothers and sisters,” said U.S. Army Veteran Johnny Compton.
Compton has been a fighter all his life, as a member of a U.S. Army Airborne division, as a mixed martial arts contender and as a longtime volunteer crime fighter for Tampa Police Department.
But now Compton is fighting for his life, after he says prescribing errors at the James A. Haley VA Hospital left him with medically induced diabetes and permanent liver damage.
“I'm terrified to go back. Terrified. Terrified,” said Compton.
Compton became infected with hepatitis during his military service and received a liver transplant in 2000.
“There are a lot of drugs that you can't take, you will have negative reactions to,” said Emergency Medicine Physician Dr. Edward Mallory. “In Mr. Compton's case, it was very common antibiotics. “
Compton hired Mallory to review his medical records and provide a medical opinion for his claim against the VA.
Compton's doctor prescribed him Zithromax in late 2013, despite manufacturer warnings that people with liver problems shouldn't take it.
“I was severely thirsty and my eyes were just going totally blind on me,” said Compton. “I couldn't understand what was going on. And my whole body was broken out.”
Compton says he called the nurse, who advised him to finish the rest of the pills in the Z-Pack container.
“He developed type two diabetes from the Zithromax,” said Dr. Mallory.
14 months later, another doctor gave Compton the antibiotic Augmentin.
The drug also carries warnings that it can cause harm to patients who have liver problems.
Compton says a pharmacist caught the mistake, but the doctor overruled him and told him to take it anyway.
Compton's adverse reaction sent him to the Emergency Room, experiencing liver failure.
Mallory says the normal protocol should have been to admit Compton to the hospital and start him on the drug Harvoni, to prevent further damage.
“They basically sent him home to die,” said Mallory.
An institutional disclosure form, which was written about 14 months after the adverse reaction, says Compton's "acute liver injury was due to the effects of Augmentin."
James A. Haley VA Hospital reported 2,602 adverse drug reactions between July 1, 2013 and July 1, 2016.
Records show 886 of the most serious cases were reported to the National Center for Patient Safety, which tracks incidents throughout the VA system.
Haley had the 12th highest number among large VA hospitals, but determined only 16 ADRs in three years were considered preventable, after conducting thorough reviews of only 18 incidents.
Dr. Mallory believes the VA should likely be doing intensive reviews of more cases.
“It's not enough at all,” said Mallory. “In the private sector, there are mistakes made, but then there are procedures implemented to try to prevent it from happening again.
“Reported events are kind of like an iceberg. The ones that get reported are just the tip,” said Attorney Phillip Cox, who oversees University of South Florida’s Office of Quality, Safety and Risk .
As part of his job, Cox defends malpractice claims filed against U.S.F. and its physicians.
Cox says he considers the VA hospital system a leader in tracking trends and outcomes, so he was surprised to see data we obtained through a Freedom of Information Act request which showed reported adverse medication events varied widely among large VA Hospitals.
The Los Angeles VA Hospital, for example, reported only seven adverse medication events in three years, despite seeing more than a million patients a year.
The Birmingham, AL VA Hospital had the highest number of reported events, at 3,776.
Cox believes that shows that Birmingham likely has a much more robust reporting procedure.
“If your numbers are low, you're not hearing enough. You're not hearing about the events that occur,” Cox said.
He says information from these reports is used to help drug companies spot potential drug interactions, identify trends and put systems in place to prevent future occurrences and improve outcomes.
Haley's spokesperson can't comment on Comptons' case, but says "We regret any preventable ADRs and strive for consistent performance improvement."
The VA statement goes on to say:
"We take the safety of all our patients very seriously. During this three-year period, JAHVH had approximately 36,000 hospital admissions and 3.75 million outpatient visits and the number of reports we generate seems to be consistent with other VA facilities of our size. We regret any preventable ADR and strive for consistent performance improvement. After internal review, 16 reported events were found to be preventable ADRs over that three years period and education was provided to the health care staff."
Compton filed a damages claim against the VA for his injuries, but the VA denied it, finding no negligence.
But Compton says he will continue to fight in court.
“This ain't just about me no more,” he said. “We're the first line of defense for this nation. Without us, you have nothing. “
If you have a story you’d like the I-Team to investigate, contact us at email@example.com