OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Healthcare Inspection – Alleged Inadequate Airway Management, Jack C. Montgomery VA Medical Center, Muskogee, OK
Report Number: 12-02618-252 Download
Issue Date: 8/15/2012
City/State: Muskogee, OK
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

OIG evaluated allegations of inadequate airway management. We did not substantiate the allegation that providers were not competent in airway management. The facility’s medical officer of the day (MOD) is responsible for airway management during non-administrative hours. All MODs had documented competence in airway management. We did not substantiate the allegation that registered nurses (RNs) intubated outside their scopes of practice. VHA and local policy permit RNs with appropriate training and demonstrated competence to intubate patients in emergent situations outside of the operating room. We did not determine that intubation by an RN contributed to a patient’s death. An RN intubated a patient at the request and under the supervision of the MOD, and the MOD checked placement of the endotracheal (ET) tube. Although autopsy revealed misplacement of the ET tube, we concluded that clinicians exercised appropriate diligence when they attempted intubation as part of resuscitative efforts and were unable to explain the autopsy finding. We did not substantiate the allegation that subsequent to the patient’s death, the facility created a policy permitting RNs to intubate. The facility has had an emergency airway management policy in place since November 2005. The local policy, which is consistent with VHA policy, does not preclude RNs from performing ET intubation and airway management in a non-operating room setting. We made no recommendations.