Philly VA Faulted in Death

By Walter F. Roche Jr.

Multiple failures at a Veterans Administration facility in West Philadelphia may have contributed to the unexpected death of a drug dependent patient in late 2017, according to a report issued today by the VA's Inspector General.
According to the report the failures continued even after the unnamed veteran in his mid-30s had passed away on his 10th day of treatment.
The report states that the drug dependent veteran was being treated with methadone after testing revealed elevated levels of oxycodone. He had been sent to Unit 7E, a 20 bed acute behavioral mental health unit.
Citing failures to communicate and failure to respond to symptoms of over-sedation, the IG concluded that opportunities for early intervention were squandered.
The staff failed to monitor EKG changes and did not adequately investigate possible adverse drug interaction, the IG found.
On the day of his death, the IG found, two care givers gave conflicting reports in patient records on the amount of methadone actually administered on that critical day.
And when the patient was found unresponsive on the 10th day of treatment, "Unit 7E was not adequately prepared to effectively respond to the patient's cardiac arrest."
Though some corrective changes were implemented after the 2017 death, the IG found the investigation was deficient because two key caregivers were involved in the analysis.
The Root Cause Analysis of the incident failed to comply with Veterans Health Administration requirements because two caregivers were involved in the analysis, thus creating the possibility of bias.