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

Thumbnail Image
Serial Number
Levin Center Identifier
Document Date
Report Length
376 pages
Policy Agendas Project Major Code
Policy Agendas Project Minor Code
Additional, Minority, Dissenting Views
Found Using Methodology
Idependent Author(s)
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.
Press Releases and Contextual Information
Related Hearings
Authors–Congress Members
Authors–Staff Members
Authors–Ex Officio Members
Authors–Additional, Minority, Dissenting Views