Quality of Care Concerns Regarding a Patient Who had Cardiac Surgery at the VA Ann Arbor Healthcare System, Michigan

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning the care of a patient who underwent cardiac surgery in 2015 at the VA Ann Arbor Healthcare System in Michigan. The OIG was unable to substantiate that the patient received inappropriate care during cardiac surgery that ultimately led to death. A cardiopulmonary bypass (CPB) catheter that was inserted to divert blood flow from the heart became misplaced. The patient did not receive adequate blood flow to the brain during surgery and died six days later. The OIG was unable to determine how or when the CPB catheter became misplaced. Review of the electronic health record and interviews determined the placement of the catheter, initiation of CPB, and maintenance of CPB during most of the surgery appeared unremarkable. Misplacement of the CPB catheter was discovered towards the end of the procedure, when attempting to restore normal blood flow through the heart. In response to one of the three allegations, the OIG confirmed that the anesthesiologist was present for the critical points of the procedure and did not abandon the patient during surgery. The OIG reviewed the facility’s quality management processes including root cause analysis, peer review, and disclosure records. Not all required processes were completed. Additionally, the facility did not evaluate the modifications that the surgeon and anesthesiologist made in their practices after the patient’s surgery through a systemic quality review to determine if the modifications might be successful or improve patient care. The OIG made one recommendation to the Veterans Integrated Service Network Director related to the facility’s compliance with quality management processes requirements, and one recommendation to the facility Director related to the surgeon’s and anesthesiologist’s modifications in their practice.