The VA Office of Inspector General (OIG) reviewed an allegation that a patient experienced a delay in receiving basic life support (BLS) during a medical emergency on the grounds of the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona, and later died at a community hospital.The OIG determined the patient experienced a delay in receiving BLS. The OIG learned of deficiencies related to the initiation of emergency medical care, including (1) conflicting facility policies that were inconsistent with Veterans Health Administration (VHA) requirements, (2) lack of layperson cardiopulmonary resuscitation (CPR) training, and (3) lack of an automatic external defibrillator (AED).Quality of care concerns were also identified, which included a discrepancy between the documented plan for a wearable cardioverter defibrillator (WCD) and the absence of an order for the device, and a failure to assess vital signs at an appointment preceding the medical emergency. The OIG was unable to determine whether a change in care would have resulted in a different outcome for the patient.Facility leaders’ lack of response upon awareness of the event did not align with high reliability organization (HRO) principles and I CARE values. The OIG identified the patient safety manager did not facilitate a thorough investigation of the related patient safety report, which resulted in an inaccurate harm assessment. Additionally, the patient safety manager and Facility Director failed to ensure a timely review of the report and investigation.The OIG made 10 recommendations to the Facility Director related to congruence of facility policies and their alignment with VHA Directives, layperson CPR training, placement of AEDs at the facility, outpatient clinic compliance with vital signs completion, complaint review processes, communicating in alignment with HRO and I CARE values, training on patient safety reporting, and investigation and closure of patient safety reports.
Phoenix, AZ
United States
