Alleged Deficiencies Related to the Cardiac Catherization and Electrophysiology Laboratories at the Jesse Brown VA Medical Center, Chicago, Illinois

The VA Office of Inspector General (OIG) initiated an inspection to assess allegations regarding concerns with cardiology procedures at the facility and evaluated facility leaders’ responses to reports of deficiencies in the Cardiac Catherization and Electrophysiology Laboratories. The OIG substantiated that complications occurred in 13 of 22 patients who underwent cardiac procedures at the facility, two of which resulted in death. The OIG team reviewed the electronic health records of the 13 patients for adverse clinical outcomes and determined that the complications, including the deaths, were not due to deficiencies or failure to follow Veterans Health Administration policy, and were consistent with known risks associated with cardiac procedures. The OIG also determined that, in response to the death of the patient who underwent a cardiac catheterization procedure, facility leaders followed policy and initiated quality reviews. The OIG did not substantiate that an anesthesiologist had concerns about the Cardiac Catheterization Laboratory. However, the OIG found that the Chief of Anesthesiology had a concern about the pre-procedural workup of the subject patient, which facility leaders addressed. The OIG found that the Cardiopulmonary Resuscitation Committee meeting minutes lacked a way to identify a specific patient code event; however, a June 18, 2019, OIG Comprehensive Healthcare Inspection Program team recommended the committee review each resuscitative episode; therefore, this report will make no further recommendations related to the committee. The OIG substantiated that the Acting Chief of Staff was aware of issues in the Cardiac Catheterization Laboratory but did not substantiate that no follow-up action occurred. The Acting Chief of Staff was aware of the eight other patients identified in the allegation and the subject patient’s death and partook in reviews. The OIG did not substantiate that a cardiologist was not present during procedures or that fellows performed procedures independently. The OIG made no recommendations.