Last year, "Walter Reed" became a rallying cry for the veterans' movement. This year, it may be "Marion, Illinois."

In June 2007, a combat-disabled Vietnam veteran went to the VA hospital in Marion, IL, complaining of chest and abdominal pain. Tests quickly revealed he had suffered a ruptured spleen and needed urgent surgery. After the operation, his heart blood pressure fell dangerously. He desperately needed an immediate blood transfusion. Adequate blood was prepared for this patient, but because the transfusion was administered too late, the patient died.

According to a recent VA Inspector General's report, this is just one of the 19 deaths in the last two years that were linked to substandard care at the Marion VA. Among the IG's conclusions:

• The surgical specialty at the Marion VA was "in disarray." There were serious problems with the quality of care before, during and after surgery.

• Oversight at the hospital was "fragmented and inconsistent."

• There were serious "deficiencies in the credentialing of physicians." In multiple instances, "physicians were privileged to perform procedures without any documentation of current competence to perform those procedures."

The VA has taken steps to resolve the scandalous treatment of veterans at this hospital. VA leadership has apologized to the families of the victims, and is assuring the public that this was an isolated incident.

As we were with the Walter Reed fiasco, IAVA will be out in front, ensuring that this latest scandal is resolved. And our commitment doesn't flag. Long after the story fades from the headlines, IAVA follows up, tracking the results and holding politicians' feet to the fire if they leave the job unfinished.