Report Summary

Title: Healthcare Inspection – Patient Death Following Failure to Attempt Resuscitation, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
Report Number: 17-01208-07 Download
Issue Date: 11/7/2017
City/State: Ann Arbor, MI
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General conducted a healthcare inspection to evaluate the circumstances that led to the failure to resuscitate a patient with full-code resuscitation status, who arrested and died at the VA Ann Arbor Healthcare System, Ann Arbor, MI. We found that a nurse caring for the patient incorrectly informed staff members that the patient had a Do Not Attempt Resuscitation order. This wrong status was relayed to staff who responded as part of the Rapid Response Team. Resuscitation was not initiated, and the patient died. It is not clear whether resuscitation efforts would have been successful if employed at the time. VA staff caring for patients must be aware of resuscitation status; however, inadequate safety measures were in place. The VA Ann Arbor Healthcare System’s Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation policies were not consistent in identifying the staff responsible for determining a patient’s resuscitation status prior to initiating resuscitative efforts. Do Not Attempt Resuscitation orders were not linked to the Clinical Warnings, Allergies, and Directives tab in patients’ electronic health records. We identified a misperception among physician staff that all patients on a telemetry unit were monitored via telemetry (continuous monitoring of heart rate and rhythm from a remote location), regardless of whether a telemetry order had been entered. Also, electronic health record documentation did not comply with requirements for resident supervision, medical decision-making, and resident physician to attending physician discussion of care during an emergency situation. We made six recommendations.

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