Healthcare Inspection – Emergency Department Patient Deaths’ Memphis VAMC, Memphis, Tennessee

The OIG conducted an inspection in response to an allegation of inadequate care for patients who died in the Emergency Department (ED) at the Memphis VA Medical Center (facility), Memphis, TN. The complainant alleged that a patient died after a physician ordered a medication for which the patient had a known drug allergy; another patient died after being administered multiple sedating drugs and not being monitored properly; and a third patient died after delays in getting treatment for very high blood pressure. We substantiated that a patient was administered a medication, in spite of a documented drug allergy, and had a fatal reaction. Another patient was found unresponsive after being administered multiple sedating medications. A third patient had critically high blood pressure that was not aggressively monitored and experienced bleeding in the brain. We found that the facility had completed protected peer reviews of the care for all three patients. Two of the deaths were also evaluated through root cause analyses (RCAs), however, we found that RCA action plan implementation was delayed and incomplete. We recommended that the Facility Director confer with Regional Counsel for possible disclosure to the surviving family member(s) of Patient 3, and ensure that processes are strengthened to monitor RCA action plans. We also recommended that processes be strengthened to improve patient monitoring in the ED, and that unit specific competency assessments be completed for ED nursing staff. The Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided an acceptable action plan.