Report Summary

Title: Healthcare Inspection – Operating Room Concerns, Marion VA Medical Center, Marion, Illinois
Report Number: 14-04310-280 Download
Report
Issue Date: 5/5/2016
City/State: Marion, IL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted
Summary:

The VA Office of Inspector General Office of Healthcare Inspections conducted a review to determine whether leadership responded to complaints at the Marion VA Medical Center, Marion, IL, that the vacuum suction in the operating room (OR) was not adequate for safe patient care and that patients were harmed as a result of inadequate vacuum suction.

We did not substantiate that facility leadership failed to respond to complaints regarding insufficient vacuum suction in the OR. Facility leadership initiated multiple actions. We did not substantiate that the vacuum suction was unacceptable for safe airway management. In mid June 2014, testing showed the vacuum suction was meeting the Advanced Cardiovascular Life Support guideline recommendation. We did not substantiate the allegation that three patients were harmed as a result of inadequate vacuum suction in the OR. The allegation did not specifically identify the patients who had reportedly been harmed. We identified one patient with similar clinical circumstances as one of the three patients described in the allegation. We interviewed staff who were involved in the patient’s procedure who indicated that, for this patient, the vacuum suction level was adequate. We were unable to identify the other two patients who may have suffered harm as alleged. While not part of the original complaint, we found inconsistent documentation of repairs and follow-up testing of the facility’s medical gas system. On September 22, 2015, we requested and subsequently reviewed 4 quarters of the facility’s engineering service monitoring tool showing implementation of the action plan to monitor the medical gas system in the OR and post anesthesia care unit. Because the facility had initiated activities to review the finding and implemented action items, we made no recommendations.