Communication lapses led to 16 patient deaths at Memphis VA hospital, OIG says

A report by the Office of Inspector General revealed 16 preventable patient deaths in a two-year period and unsanitary conditions at the Memphis, Tenn.-based Veteran Affairs Medical Center, according to WREG.

From October 1, 2015, through September 30, 2017, nine Memphis VA patients developed pressure ulcers while receiving care at the facility; 16 patients with serious treatable conditions died at the facility; and two patients developed catheter-related bloodstream infections. Unsanitary conditions included soiled furniture and dirty air ducts in food preparation areas.

Hospital officials attributed the issues to a lack of communication, personnel and training. The facility typically has stable executive leadership and active engagement with employees, the report stated.

"Memphis VA Medical Center appreciates the inspector general's review, which focuses mostly on events that occurred under the facility's previous leadership dating back to 2014," hospital officials said in a statement obtained by WREG.

"Since then, VA has appointed a new facility director, made a number of key leadership changes and lowered the facility's mortality rate to .81 percent — among the lowest of all VA facilities in this region. While the inspector general found a number of opportunities for improvement, we welcome the scrutiny and consider this an opportunity to redouble our efforts to serve veterans."

More articles on clinical leadership and infection control: 
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Nurse attitudes vs. knowledge: Which is linked to greater infection control compliance?

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