Patient died at VA hospital after alarm was ignored

Patient died at VA hospital after alarm was ignored
By CHARLES ORNSTEIN AND TRACY WEBER
ProPublica
Published: May 15, 2012

Stars and Stripes coverage of veterans issues

Registered nurses at a Manhattan Veterans Affairs hospital failed to notice a patient had become disconnected from a cardiac monitor until after his heart had stopped and he could not be revived, according to a report Monday from the VA inspector general.

The incident from last June was the second such death at the hospital involving a patient connected to a monitor in a six-month period. The first, along with two earlier deaths at a Denver VA hospital, raised questions about nursing competency in the VA system, ProPublica reported last month.

The deaths also prompted a broader review of skills and training of VA nurses. Only half of 29 VA facilities surveyed by the inspector general in a recent report had adequately documented that their nurses had skills to perform their duties. Even though some nurses "did not demonstrate competency in one or more required skills," the government report stated, there was no evidence of retraining.
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