Healthcare Inspection: Review of an Unexpected Death North Chicago VA Medical Center North Chicago, Illinois

摘要

The purpose of the review was to determine the validity of allegations regarding the care provided to a patient who died within 24 hours of admission to the North Chicago VA Medical Center (the VAMC). The complainant suggested that a medical trainee may have been inadequately supervised. We found deficiencies in the quality of care provided for this patient, but we did not demonstrate a connection with the patients death. A physician conducted an evaluation approximately 5 hours before the patients cardiopulmonary arrest, but the patients subsequent restlessness and hypoxemia should have prompted an assessment of underlying causes prior to administration of an intravenous (IV) sedative. The sedative and an IV narcotic were administered at reasonable doses, but this combination might best have been avoided during a pursuit of an explanation for his restlessness and hypoxemia. Although the VAMC has a procedure in place for the expeditious assessment of patients whose condition is worsening, physician and nursing personnel did not take advantage of this resource. We recommended that management officials evaluate this case with Regional Counsel for possible disclosure to the patients family and ensure that staff comply with the VAMCs policy for rapid intervention in patients with deteriorating clinical conditions. Management submitted appropriate implementation plans.