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Congresswoman Debbie Dingell

Representing the 12th District of Michigan

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Dingell, Walberg Seek Information from Ann Arbor VA on Efforts to Respond to Fatal Do-Not-Resuscitate Mistake

November 9, 2017
Press Release

WASHINGTON, D.C. – Following the tragic death of a veteran at the VA Ann Arbor Healthcare System after confusion over a Do Not Attempt Resuscitation (DNAR) order, U.S. Representatives Debbie Dingell (MI-12) and Tim Walberg (MI-07) today sent a letter to VISN 10 Network Director Robert McDivitt and VA Ann Arbor Acting Director Andrew Pacyna requesting information about all efforts being taken to implement recommendations made by the Veteran’s Affairs Office of Inspector General (OIG) to prevent a similar tragedy in the future. 

“It is critical that we fully understand the actions being taken to implement the OIG’s recommendations so that we can ensure that a similar tragedy never happens again,” the Representatives wrote. “Patient care and safety must be the top priority at the VA Ann Arbor Healthcare System. Our veterans have made great sacrifices for our nation, and we have an obligation to make sure they are properly cared for during all treatment.”

The OIG report released this week 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 lifesaving recommendations for our veterans,” the Representatives continued. “We would also request an estimated timeline for meeting these recommendations and to receive regular updates throughout the process.”

The full letter can be read here and below. 

November 9, 2017

Mr. Robert McDivitt                                                    Mr. Andrew Pacyna     
Network Director                                                         Acting Director            
Veterans Integrated Service Network 10                    VA Ann Arbor Healthcare System
11500 Northlake Drive, Suite 200                               2215 Fuller Rd             
Cincinnati, OH 45249                                                  Ann Arbor, MI 48105

Dear Director McDivitt and Acting Director Pacyna:

This letter is regarding the tragic death of a veteran at the Ann Arbor VA Medical Center and a subsequent report by the U.S. Department of Veterans Affairs Office of Inspector General (OIG).  The report found that a nurse mistakenly thought the veteran had a Do Not Attempt Resuscitation (DNAR) order and therefore did not attempt to revive the veteran who then passed away.  The OIG recently issued a report on this tragedy and made several important recommendations.  It is critical that we fully understand the actions being taken to implement the OIG’s recommendations so that we can ensure that a similar tragedy never happens again. 

According to the OIG report, several factors contributed to the confusion surrounding the veteran’s DNAR status, but it is clear that there was no standardized process to manage the communication of a patient’s resuscitation status between nurses and doctors. It is even more troubling to learn that the existence of vulnerabilities related to confirming resuscitation status—particularly during worsening patient conditions—were identified by VA leadership a year prior to this incident and no remedial measures were taken. 

The OIG has made six specific recommendations, including requiring staff to immediately verify resuscitation status of patients; ensuring that DNAR and the Cardiopulmonary Resuscitation orders align with one another; improving staff training and education; obtaining an independent external review; and other administrative 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 lifesaving recommendations for our veterans.  We would also request an estimated timeline for meeting these recommendations and to receive regular updates throughout the process. 

Patient care and safety must be the top priority at the VA Ann Arbor Healthcare System.  Our veterans have made great sacrifices for our nation, and we have an obligation to make sure they are properly cared for during all treatment.  Thank you for your attention on this important matter and for the swift actions already being taken to ensure our veterans are receiving the highest level of care moving forward.


Sincerely,

Issues: