According to the Washington Post, there have been 19 suicides on VA campuses, and seven of them have occurred in parking lots.

Justin Miller, a 33-year-old Iraqi vet and trumpet player, entered a Minnesota veteran’s hospital for treatment of PTSD. He was discharged home on his fourth hospital stay, got into his truck and committed suicide with a firearm.  A VA Inspector General’s report found several preventable le mistakes that were committed at Miller’s discharge.  The operative word is “preventable.”

Let’s move from the VA hospital system to U.S. maternity wards where an estimated four million babies are born each year in the U.S.  According to CDC, 700 pregnant women, and new mothers die each year with 60% of those deaths being preventable.  Most of these avoidable deaths for both hospital systems are the result of “system errors” which in plain English means, someone didn’t follow protocol. Someone missed a diagnosis. Someone clearly messed up.

Miller was sent home without a family member present or informed. No one bothered to determine if he possessed any firearms or where were they located? His symptoms were misdiagnosed as not being severe enough to remain in the hospital longer. Conversely, postpartum moms are sent home with borderline elevated blood pressures without immediate follow up appointments. Or, they will present to the emergency department with complaints of a headache, and no one will make a presumptive diagnosis of preeclampsia because their blood pressures aren’t soaring through the roof.

In the future, this author plans on educating the public about the evils of system errors in healthcare and how they can be reduced or even presented. Our veterans and pregnant women deserve the best possible care, and there is no logical reason why they shouldn’t receive it.

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