Care Concerns and Deficiencies in Facility Leaders’ and Staff’s Responses Following a Medical Emergency at the Carl T. Hayden VA Medical Center in Phoenix, Arizona.

This investigation from the VA Office of Inspector General (OIG) reviewed a patient care delay in receiving basic life support services while on VA medical center grounds, who later died at another facility. Explorations into causal factors determined policy inconsistency, equipment unavailability, and training gaps as problematic. At the system level leadership response and poor incident analysis and reporting negated improvement opportunities that align with the high reliability organizational attainment goals of the VA.