#Middlebury #Veterans #OIG #PatientCareErrors
VETERANS POST
By Freddy Groves
Telemetry medicine is a huge benefit for surgery or cardiac patients. Using fancy high-tech equipment, these patients can be monitored while they recover, and their vital signs are continuously transmitted to medical staff. So, it’s great … except when it’s not.
The Department of Veterans Affairs’ Office of Inspector General recently investigated two cases where the whole system failed because of human actions. In one case, the technician changed the alarm on the device and put it on “Do Not Disturb.” That technician didn’t complete a required Patient Safety Report, and a nurse didn’t document the patient’s condition (another required Patient Safety Report) after finding the patient unresponsive and without a pulse.
In another case, the patient himself reported cardiac symptoms but there was a delay in anyone knowing because the technician had turned off the monitoring alarms. Although a Patient Safety Report was done later, a manager rejected it, which apparently meant that the OIG couldn’t talk to staff about the incident.
The OIG, of course, had recommendations. None of those recommendations, unfortunately, involved firing the technicians that actually turned off patients’ alarms on the equipment.
In another investigation, medical staff didn’t give the required informed consent information to a patient who was held involuntarily in a locked mental health unit for 48 hours. The patient had gone to the ER and asked for help with substance withdrawal. He was admitted and was apparently surprised it was a locked mental health unit that he was put in (he was concerned about the behavior of those around him) and wanted to leave. The next day the patient put his request to leave in writing and was finally let out the following day. Problem was, according to state law, he should have been released immediately after filing that request.
Again, the OIG had recommendations, one being that the policies need to align with state laws. Sometimes the VA does this well, and then there are incidents like these.
© 2024 King Features Synd., Inc.
