Bad notes, alerts, blamed for VA deaths

Memphis VA Medical CenterMemphis VA Medical Center

Clinicians bypassed medical center’s policy of digital documentation, missed alerts at Memphis center

Three recent deaths at the Memphis VA Medical Center emergency department could probably have been prevented with better communication, digital documentation and better layout of the emergency department, according to an investigation by the Veterans Administration Inspector General.

After receiving an anonymous complaint describing potential inadequate care incidents at the Memphis VA Medical Center’s 22 bed ED, the VA Office of the Inspector General reviewed committee minutes, relevant documents, and the electronic health records of the patients, and largely substantiated the claims, finding physicians missing nurse notes and EHR alerts, and a poor ED design leaving some patients only partly monitored.

One patient came to the ER complaining of back and neck pain and confirmed an aspirin allergy with a nurse upon arrival, but the physician reviewing the patient three hours later hand-wrote on paper an order for the aspirin-containing anti-inflammatory drug ketorolac, missing an alert that would have noted a contraindication and bypassing the medical center’s policy of digital documentation.

[See also: Healthgrades ratings tied to death risks.]

The OIG found that ED staff also missed an alert, or an alert never went off, for the second patient, who came into the ED complaining of severe back pain. Soon after receiving a combination of narcotics, sedatives and tranquilizers, s/he developed low oxygen levels, became unresponsive and died in a coma 13 days later, according to the OIG report.

Located in a less-urgent Level 2 ED bed that did not stream data on patient vital signs, electrocardiograms and oxygen levels to the central monitoring system, the patient’s portable oxygen saturation monitor may have beeped an alert and staff did not hear it, or the device may have slipped off the patient’s finger, according to the OIG’s investigation.

[See also: Commonwealth shows 'stark' care divide.]

The problem could also have stemmed from the device not working. A later review by Memphis VA Medical Center staff found that the oxygen monitor had stopped recording data about 40 minutes before the patient was found, almost immediately after receiving the medication, although the monitor proved to work consistently in tests.

Either way, when an RN checked in 45 minutes after the medication was administered, the patient was already unresponsive and not breathing.

In all of the cases, the OIG found that some nursing staff lacking competencies validated for ED-specific skills, and, especially in the case of the second patient, raised concerns over the facility’s ED layout design — an issue identified as a risk during a prior inspection.

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