Bioethics Blogs

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.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.