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

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Serial Number
Levin Center Identifier
Document Date
2016-05-31
Report Length
376 pages
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Additional, Minority, Dissenting Views
Found Using Methodology
Yes
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Brief Executive Summary
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.
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