Factors Contributing to the Death of a Ventilator-Dependent Patient at the VA San Diego Healthcare System, California

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate factors that may have impacted or contributed to the unexpected death of a ventilator-dependent patient on the Spinal Cord Injury (SCI) unit at the VA San Diego Healthcare System and to follow-up on the facility’s response. The OIG could not determine what the ventilator settings were at the time of the patient’s death, because facility staff who inspected the ventilator immediately thereafter changed the settings to check whether alarms were functional and then reportedly returned the settings to the previous levels. The OIG determined the facility did not implement risk mitigation strategies for the use of the in-line Passy-Muir® Valve (PMV) on ventilated patients. The facility did not have a back-up monitoring plan when the ventilator alarms were off, patient criteria to determine when the valve should be removed, policies for facility staff and patient/family education on the use of the PMV, policies or procedures for monitoring and documenting ventilator and alarm settings while using the PMV, or a policy to use anti-disconnect devices. At the time of the patient’s death, the SCI unit used an outdated nurse call system that required the use of a splitter to connect the ventilator to the call system, none of the respiratory therapy staff had training or competency assessments related to PMV use, staff failed to report the patient’s ventilator tubing disconnections through the Patient Safety reporting system, and SCI leaders failed to follow the standard operating procedure for the management of clinical alarms. The OIG made five recommendations related to policy and training for use of the PMV on the SCI unit and the anti-disconnect device, potential issuance of a National Patient Safety Advisory, training for reporting patient safety issues, and reviewing clinical alarms according to facility policies.