The U.S. House Committee on Veterans’ Affairs has begun an investigation into the Memphis VA Medical Center after an inspector’s report found three patients had received substandard care and died.
A letter from the committee chairman, Rep. Jeff Miller, to the Department of Veterans Affairs on Wednesday mentions three patients who died in the hospital’s emergency room.
The Florida Republican’s letter requests information from the department including action plans related to the patients, along with peer reviews, performance reports and disciplinary actions for the medical professionals involved in their treatment.
A VA inspector general’s report released Oct. 23 said one patient was given a medication despite a documented drug allergy and had a fatal reaction.
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Another patient was found unresponsive after receiving multiple sedating medications. A third had critically high blood pressure that was not aggressively monitored and experienced bleeding in the brain about five hours after going to the emergency room, the report said.
The report recommended that the hospital strengthen plans to identify the cause of a patient’s problem and take action; improve monitoring of emergency patients; and complete competency reviews for emergency nursing staff.
The hospital issued a statement saying it addressed the recommendations. The medical center said it has corrected issues identified by the action plan and that the physician involved in the care of two of the patients in the report is no longer working there.
The hospital also established a tracking system to make sure action plans are timely and complete, and began placing all patients in the emergency department area on cardiac monitors, according to a VA statement Wednesday. Also, a nurse has been assigned to make sure nurses have appropriate emergency qualifications.
Miller’s letter says the committee is requesting the information, “given the patient deaths and the apparent inability of the VA to implement corrective actions at the Emergency Department in Memphis.”
“VA owes the families affected by these tragic preventable veteran deaths a full explanation of what went wrong,” Miller said in an email to The Associated Press.
The VA’s inspector general also issued a report in August 2012 identifying issues with inadequate monitoring of patients in the Memphis VA hospital’s emergency room. The length of stay in emergency room was far below the VA’s standard and software related to wait times was unreliable, the report said.
However, the same report also said investigators reviewed 38 patients’ electronic health records and did not find that they experienced negative outcomes as a result of excessive length of stays in the emergency department.
Date: November 20, 2013