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Report on Incorrect DNR Order from Veterans Affairs Inspector General

In October 2014, I blogged about the case of Roland Mayo.  A California VA facility had erroneously placed a DNR order on him.

A few days ago, the Department of Veterans Affairs Office of Inspector General released a new report titled “Healthcare Inspection: Delay in Emergency Airway Management and Concerns about Support for Nurses VA Northern California Health Care System Mather, California.”

The OIG found:

  • Facility staff did not follow through on the patient’s request upon admission to discuss advance directives. We found no evidence of advance care planning discussion during the patient’s hospital stay.
  • The patient’s wristband had the incorrect code status of Do Not Resuscitate/Do Not Intubate printed on it and that staff did not verify the wristband code status during the patient’s 9-day hospital stay. 
  • The wristband had clinical warnings not pertinent to the patient’s current condition. We determined that a contributing factor as to why staff did not identify the incorrect code status might have been that nurses were using a duplicate copy of the wristband as a “workaround” when administering medications.
  • The incorrect code status on the patient’s wristband led to a delay in life-saving intervention. We concluded that code status confusion delayed chest compressions, defibrillation pad placement, and medications. The anesthesiologist was turned away and called back later, causing a delay in intubation. Of note, the patient was actively being managed by the code team physician during this time.

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