Memphis VA center inspected for inadequate care after patient de - FOX13 News, WHBQ FOX 13

Memphis VA center inspected for inadequate care after patient deaths

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    Friday, October 4 2013 3:43 PM EDT2013-10-04 19:43:45 GMT
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MEMPHIS, Tenn. (FOX13) -

A report was released Wednesday from the Department of Veterans Affairs Inspector General into an allegation of inadequate care for patients who died in the Emergency Department at the Memphis VA Medical Center on Jefferson Avenue.

DOWNLOAD the report: Healthcare Inspection – Emergency Department Patient Deaths' Memphis VAMC, Memphis

The complainant alleged that a patient died after a physician ordered a medication for which the patient had a known drug allergy; another patient died after being administered multiple sedating drugs and not being monitored properly; and a third patient died after delays in getting treatment for very high blood pressure.

The OIG substantiated that a patient was administered a medication, in spite of a documented drug allergy, and had a fatal reaction. Another patient was found unresponsive after being administered multiple sedating medications. A third patient had critically high blood pressure that was not aggressively monitored and experienced bleeding in the brain.

The report said the Memphis VA Medical Center had completed protected peer reviews of the care for all three patients. Two of the deaths were also evaluated through root cause analyses (RCAs), however, the OIG found that RCA action plan implementation was delayed and incomplete.

The OIG recommended that the facility director confer with Regional Counsel for possible disclosure to the surviving family member(s) of Patient 3, and ensure that processes are strengthened to monitor RCA action plan. It also recommended that processes be strengthened to improve patient monitoring in the ED, and that unit specific competency assessments be completed for ED nursing staff.

The Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided an acceptable action plan.

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