Two Michigan U.S. representatives are requesting information on a do-not-resuscitate order that was issued by mistake at Ann Arbor's VA hospital last year.
A veteran who had had bypass surgery died at the hospital after a nurse mistakenly believed he didn't want to be resuscitated in an emergency, according to the Associated Press.
U.S. Reps. Debbie Dingell, D-Dearborn; and Tim Walberg, R–Tipton, sent a letter to VISN 10 Network Director Robert McDivitt and VA Ann Arbor Acting Director Andrew Pacyna on Thursday, requesting information about efforts to prevent a similar incident.
“It is critical that we fully understand the actions being taken to implement the (Office of Inspector General) recommendations so that we can ensure that a similar tragedy never happens again,” the representatives said in a news release.
According to the AP, while recovering from surgery, the patient complained about chest pain and nausea. A nurse left the room to get an electrocardiogram machine, but the man was unresponsive with abnormal breathing when the nurse returned, the report said.
As a result of the death, the nurse no longer provides direct care, investigators said, noting that it was the third time in four years that he was “involved in significant monitoring deficiencies in high-risk patients.”
The report made six recommendations to the VISN Director including requiring staff to immediately verify resuscitation status of patients; ensuring that DNAR and the Cardiopulmonary Resuscitation orders align with one another; and improving staff training, among other recommendations.
“While you have concurred with each of these recommendations, we would request a full response regarding all efforts being taking to implement these potentially life-saving recommendations for our veterans,” the representatives wrote. “We would also request an estimated timeline for meeting these recommendations and to receive regular updates throughout the process.”