Becker's Hospital Review

12 INFECTION CONTROL & PATIENT SAFETY Federal report details lapses at Ohio VA hospital where patient died in 2017 By Anuja Vaidya T he Veterans Affairs Office of the Inspector Gen- eral released a report Feb. 20 detailing patient care issues at Dayton (Ohio) VA Medical Center that may have contributed to the death of an elderly patient, according to Dayton Daily News. e VA OIG first received complaints about the hospi- tal in December 2017, alleging the hospital's emergen- cy department and a nurse made errors related to the death of the patient. During the inspection, the VA OIG found that there were problems with the ED's handing of the patient and facility operations. A physician was implicated as well, but not an RN. e report shows that when the patient was admitted to the ED, the physician put in an order for a drug that the patient's notes made clear should not be used. ere was also a significant delay in putting in diag- nostic test orders and incorrect documentation of the patient being moved to another department, though the ED was still waiting for test results. The patient went into cardiopulmonary arrest while staff was waiting for CT scan results. The patient died soon after. The physician was suspended and resigned in November 2019. e inspection also found issues with the facility's op- erations, including its its peer review system communi- cation issues that could result in patient harm. e VA OIG made 13 recommendations to the hospi- tal, which it agreed to follow, presenting the OIG with an action plan. e OIG will follow up with the facility to ensure it has implemented the action plan. A spokesperson for Dayton VA Medical Center told Becker's that the hospital has started implementing each the OIG's recommendations and expects to implement them all this year, including a new policy to ensure timely emergency department transfers. "e Dayton VA emergency department has safely cared for more than 75,000 veterans without incident and developed processes to ensure the facility contin- ues to provide safe, compassionate, comprehensive care to all veterans," the statement said. n Florida may require hospitals to conduct anonymous patient safety surveys By Mackenzie Bean F lorida lawmakers are considering legislation that would re- quire hospitals to conduct anonymous employee surveys on patient safety culture, reported the Tampa Bay Times. Every other year, hospitals would have to survey employees on how well their teams work together and communicate, along with whether staff members feel comfortable raising safety concerns with superiors. Survey results would then be shared with the public. The Florida House of Representatives has previously passed simi- lar proposals, which failed to gain traction in the Senate. However, the Senate Health Policy Committee passed the bill Feb. 11 in a unanimous vote. Rep. Chris Sprowls, R-Palm Harbor, credits the bill's heightened support to recent patient safety issues that have come to light at hospitals like St. Petersburg-based Johns Hopkins All Children's Hospital. In November 2018, the Tampa Bay Times published an investigative report on safety and quality issues at the hospital›s heart surgery unit. "If we were asking clinical staff on a regular basis, 'How do you feel about the quality of care at this hospital?' and it's going to be public, God knows the CEO of that hospital is going to make sure they put eyeballs on that data and that could save somebody's life," Mr. Sprowls told Tampa Bay Times. n Illinois physician's suicide note reveals unreliable vaccination practices By Mackenzie Bean H ealth officials in a southwest Chicago suburb are urging patients to check their immunization records after a well- known pediatrician left a suicide note suggesting he did not always administer required vaccines, reported The Washington Post. Van Koinis, DO, a pediatrician in Evergreen Park, Ill., took his own life in September. On Feb. 11, the Cook County Sheriff's Office disclosed the content of Dr. Koinis' suicide note. The letter implies that Dr. Koinis falsified medical records for par- ents who did not want their kids to receive vaccines required for school-aged children under Illinois law. The suicide note did not suggest that Dr. Koinis withheld vaccina- tions from parents seeking them for their children, according to the sheriff's office. It was not immediately clear which children had received required vaccines due to Dr. Koinis' poor record-keeping, investigators said. n

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