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Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.
July 26, 2023
Washington, DC: VA Office of the Inspector General; June 28, 2023. Report no. 22-02725-132.
Delays in emergency care provision can contribute to patient harm. This analysis examined an instance of cardiopulmonary resuscitation (CPR) delay and the poor response once the emergency was identified at an outpatient clinic. System-level issues flagged include incomplete incident records and follow up. Staff training, emergency notification, CPR process compliance, and debrief results completion were among the recommendations for improvement.
