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Columbia, SC (WLTX) - A federal review of veterans hospitals found that consultation delays led to six deaths at the Dorn VA Medical Center in Columbia, the highest number in the country.

Last November, another report found delays in treatment at Dorn VA. Previous Coverage: Report Finds Critical Treatment Delays at Hospital

This latest report, prepared by the Department of Veterans Affairs, was released this month, and looked at records dating back to 1999. It reviewed consults, which are a request by a provider for the clinical opinion or services of a second provider or physician. In particular, it looked at "high-interest" consults, involving health coverage areas such as oncology, gastrointestinal endoscopy, and cardiac surgery.

Nationwide, the report found 76 patients who had to be notified that as a result of their care, they could have been seriously harmed. Of those 76 who were alerted, 23 have since died. At the Dorn VA alone, however, there were 20 people who had to be notified, and 6 of them died. Both of those numbers are the highest found in the report.

The review traced the problem to an electronic system that is intended to be used to schedule appointments for patients who needed consultations. According to the report, though, the system also was used other purposes, such communication between providers and note to reserve spots for transportation vehicles. These items showed up in the system as open requests, even though they didn't actually represent patients who needed help. Eventually, these other requests became the records in the system, leading to delays in coverage.

As a result of the probe, the VA says they're changing their rules for the computer system so it will be easier to distinguish true consultations from these other requests, and the VA is training their staff.

"We continue to take action to strengthen oversight mechanisms and prevent a similar delay at other VA medical centers," the report states. "We take any issue of this nature extremely seriously and offer our sincerest condolences to families and individuals who have been affected and lost a loved one."

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