Report Summary

Title: Healthcare Inspection – Patient Equipment and Medication Safety in the Surgical Intensive Care Unit, Michael E. DeBakey VA Medical Center, Houston, Texas
Report Number: 12-00823-285
Issue Date: 9/24/2012
City/State: Houston, TX
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection in response to anonymous complainants’ allegations of unsafe patient care and delivery of services in the Surgical Intensive Care Unit (SICU) at the Michael E. DeBakey VA Medical Center (VAMC) in Houston, TX (facility). We found that the facility's average actual SICU nursing hours per patient day (NHPPD) staffing levels were below the unit’s target NHPPD. We determined that the facility assigned nurses to units without proper training, tolerated disruptive behavior, and did not properly use nurse staffing methodology. We substantiated that the SICU cardiac monitors were outdated and in need of replacement, and that equipment was in short supply.
We substantiated that the pharmacy placed SICU patients’ medications in a bin in the medication room and was slow to fill requests for urgent medications. We recommended that the Facility Director ensure that: (1) SICU nursing management reassess the nursing methodology to ensure the target NHPPD is appropriate, (2) nursing staff receive unit-specific training for each unit they are assigned, (3) outdated monitors are replaced and equipment is in sufficient supply (4) disruptive behaviors are addressed, and (5) medications are dispensed in a safe manner. The Veterans Integrated Service Network and Facility Directors agreed with our findings and five recommendations and provided acceptable improvement plans.