WASHINGTON – A Department of Veterans Affairs watchdog warned VA leadership Wednesday about ongoing “troubling incidents” that pose a risk to patient safety at the Washington, D.C. VA Medical Center and urged the department to take action immediately.

VA Inspector General Michael Missal sent a letter to Poonam Alaigh, the VA acting undersecretary for health, about problems discovered during an on-site visit his team conducted Wednesday at the DC hospital. The letter recounted an incident where a patient was prepped for vascular surgery and under anesthesia at the DC hospital Wednesday when it was discovered the surgeon didn’t have the necessary instrument to perform the operation. The surgery was then postponed.

Also on Wednesday, the inspector general’s Rapid Response Team found discolored surgical instruments that the team determined to be unsuitable to use on patients.

The findings came nearly one month after the inspector general warned VA leadership about inventory and sterilization problems at the DC hospital. The letter stated medical supply issues continue at the VA, despite department leadership saying a new inventory system had been put in place 48 hours after the initial warning and truckloads of supplies brought to the hospital in the past few weeks.

“Our Rapid Response Team was onsite today and found further troubling incidents that indicate patients are being placed at unnecessary risk,” Missal wrote. “These further incidents raise serious concerns that surgeries and other procedures requiring sterile equipment may be performed with unsuitable equipment. We therefore ask that you immediately take necessary and appropriate action to ensure that patients at the DC VA [medical center] are not placed at unnecessary risk.”