Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee.

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Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee.

January 31, 2024

Washington, DC: The Veterans Affairs Inspector General; January 10, 2024. Report No. 23-00777-52.

Communication delays are a common contributor to serious patient harm. This analysis examines a case of communication failure during cardiac telemetry processes that resulted in patient death. Communication gaps at the time of clinical deterioration affected nurse assignments and delays in care, and the subsequent review of the patient's care failed to identify systemic and causal factors.

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Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee.

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