Department of Veterans Affairs
	

Office of Inspector General
	

Healthcare Inspection
 

Post-Operative Paralysis
 

Overton Brooks VA Medical Center
 

Shreveport, Louisiana
 

Report No. 10-03462-190 June 8, 2011
	 VA Office of Inspector General
	

Washington, DC 20420
	
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Executive Summary
	

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

inspection to determine the validity of an allegation regarding post-operative paralysis at 

the Overton Brooks VA Medical Center (the medical center), Shreveport, LA. A 

complainant alleged that a patient could not move his lower extremities after the insertion 

of an epidural catheter (small hollow tube used to inject anesthetic between the spinal 

canal and spinal cord). The complainant believed that the catheter caused the patient’s 

paralysis. 

We did not substantiate the allegation. However, we found that the patient’s paralysis 

may have resulted from a prolonged period of hypotension (low blood pressure) in the 

intensive care unit (ICU). We concluded that the hypotension was poorly monitored and 

should have been treated more aggressively. 

During our review, we found that ICU nursing staff did not document required patient 

assessments. There was no documentation of the mean arterial pressures needed to adjust 

medications prescribed for low blood pressure, no documentation of the epidural catheter 

or of neurological assessments, and inconsistent documentation of verbal orders and 

administered medications. In addition, we found that the medical center’s system of 

reporting and evaluating adverse events needed improvement. 

We recommended that the Medical Center Director ensure that (1) patients in the ICU are 

assessed appropriately and patient care activities are consistently documented, and 

(2) processes are in place for reporting and evaluating adverse events. 

The VISN and Medical Center Directors agreed with our findings and recommendations. 

The implementation plans are acceptable, and we will follow up on the planned actions 

until they are completed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
	

Office of Inspector General
	

Washington, DC 20420
	

TO: Director, South Central VA Health Care Network (10N16) 

SUBJECT: Healthcare Inspection – Post-Operative Paralysis, Overton Brooks VA 

Medical Center, Shreveport, Louisiana 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted 

an inspection to determine the validity of an allegation regarding post-operative paralysis 

at the Overton Brooks VA Medical Center (the medical center), Shreveport, LA. A 

complainant alleged that an epidural catheter1 caused a patient to be unable to move his 

lower extremities. The purpose of the review was to determine whether the allegation 

had merit. 

Background 

The medical center is a tertiary care hospital that is part of Veterans Integrated Service 

Network (VISN) 16. It provides a broad range of specialty services including surgical 

service. The medical center has six operating suites and performed 2,901 major surgical 

procedures during fiscal year 2010. The services of both anesthesiologists and certified 

registered nurse anesthetics are used in the provision of anesthesia care. 

In August 2010, a confidential complainant contacted the OIG hotline with an allegation 

that a veteran received an epidural catheter for post-operative pain and that for 6 hours 

following surgery he was able to move his lower extremities; however, he later became 

paralyzed. The complainant believed that the paralysis was due to the epidural catheter. 

In November 2010, the OIG hotline received several allegations from another 

confidential complainant regarding incidents that occurred in the medical center’s 

operating room (OR). These allegations were not substantiated (see Appendix A). 

1 An epidural catheter is a small hollow tube that allows for the injection of an anesthetic drug into the space 

between the wall of the spinal canal and the covering of the spinal cord. 

VA Office of Inspector General 1 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Scope and Methodology 

Prior to our site visit, we interviewed the complainant by telephone. We conducted a site 

visit on November 17–19, 2010. We interviewed an anesthesiologist, thoracic surgeon, 

intensive care unit (ICU) nurse manager and staff nurses, risk manager, patient safety 

manager, and other clinical staff. We reviewed local and Veterans Health Administration 

(VHA) policies and procedures, the patient’s medical record and ICU nursing flow 

sheets, published journals, quality management documents, patient incident reports, 

competency records, and the American Association of Critical Care Nurses standards of 

practice. We consulted with a board-certified anesthesiologist regarding insertion of the 

patient’s epidural catheter. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Case Summary 

A patient in his seventies with chronic obstructive pulmonary disease was found to have 

an abnormal chest x-ray at the Alexandria VA Medical Center. Computed tomography2 

and positron emission tomography3 scans (March and April 2010) revealed a suspicious 

nodule in his left lower lung. An early May, lung biopsy revealed poorly differentiated 

non-small cell carcinoma. 

In early July (hospital day 1 HD1), the patient was admitted to the medical center for preoperative evaluation. On HD2, a pulmonologist noted that the patient was at substantial 

risk for post-operative pulmonary complications. A cardiologist considered the patient to 

be at intermediate risk and recommended that volume overload (too much fluid in the 

blood) be avoided. 

On HD4, the patient underwent left lower lung lobectomy.4 Prior to surgery the patient 

had an epidural catheter placed for administration of medications to control postoperative pain. 

At 3:30 p.m., the patient was transferred directly to the ICU for post anesthesia recovery 

in stable condition with an arterial line,5 two chest tubes, an epidural catheter, oxygen, 

and two peripheral intravenous (IV) lines. 

2 Computed tomography is an x-ray procedure, which provides cross-sectional images.
 3 Positron emission tomography scans detect biochemical processes in the body that may indicate disease before the
 

appearance of anatomical changes that other imaging studies may detect.

4 A lung lobotomy is a surgery in which a lobe of the lung is removed.
 5 Arterial line is a thin catheter inserted into an artery to monitor the blood pressure in real time and to obtain
 

samples for arterial blood gas measurement.
 

VA Office of Inspector General 2 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

On arrival to the ICU, an initial assessment was completed and the patient’s vital signs 

were reassessed every 15 minutes and neurological status every 30 minutes. The 

patient’s blood pressure (BP) ranged from 98/40 to 128/53 millimeters of mercury. The 

patient was noted to be lethargic but was moving all four extremities. The post 

anesthesia period ended at 4:40 p.m. The patient’s BP was 118/45 and no neurological 

deficits were noted. 

At 7:00 p.m., a nurse noted on the ICU nursing flow sheet6 that the patient began to 

develop hypotension. At that time, the patient’s BP was 85/70. The nurse recorded the 

BP every 15 minutes. An hour later, the BPs ranged from 75/45 to 88/42. At 9:00 p.m., 

the nurse phoned the resident thoracic surgeon to report the patient’s status. The nurse 

noted that verbal orders were received for blood tests (hemoglobin and hematocrit), a 

bolus7 of Lactated Ringer’s 1000 milliliters (ml) IV, and phenylephrine (drug used to 

treat hypotension) IV to maintain a mean arterial pressure (MAP)8 greater than (>) 65. In 

order to maintain perfusion of major organs a MAP of 60 is necessary. The IV bolus was 

started, but the phenylephrine infusion was not initiated at this time. 

At 9:35 p.m., the attending surgeon called the unit and verbal orders were given to the 

nurse to discontinue the fluid bolus and start a phenylephrine infusion. The nurse 

documented on the nursing flow sheet that the attending was in the ICU at 10:00 p.m. and 

that phenylephrine was infusing at that time. The patient’s BP was 97/48 at 10:00 p.m. 

At 10:45 p.m. the BP was 105/52. At 11:00 p.m., the BP started to decline again; the BP 

was 87/47. 

On HD5, at 12:00 a.m., the BP ranged from 69/37 to 76/40. At that time, the nurse wrote 

that the last three MAPs were less than (<) 60. The MAPs were not noted on the nursing 

flow sheet; however, the BPs were 78/43, 84/44, and 84/42. At 12:50 a.m., the nurse 

noted that the phenylephrine had been increased every 15 minutes without a significant 

change in the patient’s BP. A resident was called at that time and orders were received to 

discontinue the phenylephrine and to start dopamine (drug used to increase the blood 

pressure), with the dose to be adjusted to maintain a MAP of at 

least 60, and to begin albumin IV. 

At 1:00 a.m., phenylephrine was discontinued and a dopamine infusion was started. At 

1:30 a.m., the patient’s BP increased to 115/38. The patient’s IV access in the left 

forearm was discontinued after the patient complained of pain when the IV access was 

flushed. The nursing staff was unable to restart the IV and notified the resident who 

discontinued the order for albumin. At 3:00 a.m., the nurse noted on the nursing flow 

sheet that the dopamine had been effective. The patient’s BP was 99/41 at that time. 

6 The events from 7:00 p.m. on the day of surgery to 1:00 a.m., the following morning were documented on the ICU
 

nursing flow sheet.

7 Bolus is a large volume of fluid given intravenously and rapidly at one time.
 8 MAP is an average blood pressure in an individual.
 

VA Office of Inspector General 3 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

At 6:45 a.m., during his assessment of the patient, an attending anesthesiologist 

documented that the patient was “completely unable to move his legs.” The thoracic 

surgeons were immediately informed and the patient was discussed with a neurosurgeon. 

The neurosurgeon consultant evaluated the patient at 8:16 a.m. and wrote: 

He [the patient] reports some sensory changes in his legs. I did not see any 

movements even with a painful stimulus. Reflexes were absent. There was 

no clonus.9 There are several possibilities, including potential spinal cord 

infarction10 and mass lesion. He was noted to be hypotensive in SICU and 

required two pressors to maintain his BP over night. A combination of 

thoracotomy and hypotension could definitely cause an infarction. An 

epidural catheter placement can cause a mass effect if there was a 

hematoma around the cord. 

A magnetic resonance imaging (MRI) scan was obtained to determine if a hematoma was 

evident around the epidural catheter. The radiology report revealed, “Diagnostic 

consideration includes spinal cord infarction,11 myelitis.12 No evidence of paravertebral 

soft tissue hematoma seen.” After the MRI, the epidural catheter was removed. 

On HD6, the patient continued to report inability to move his legs, with sensation to 

touch and position sense on his feet, but no sensation to pain. The patient had slightly 

more sensation on his chest and abdomen and was feeling the chest wound, which he 

previously reported to be numb. 

On HD7, the patient developed respiratory distress and subsequently was intubated and 

placed on a ventilator. The patient received a tracheostomy13 on HD11. 

On HD20, the patient was discharged to a non-VA long term acute care facility. At that 

time, the patient had some movement of the right leg but no movement of the left leg. 

The patient died 9 weeks later. 

9 Clonus is an abnormality in neuromuscular activity characterized by rapidly alternating muscular contraction and
 

relaxation.
 10 Infarction is an area of tissue that undergoes necrosis (death) resulting from obstruction of the blood supply.
 11 Spinal cord infarction occurs when one of the three major arteries that supply blood (and therefore oxygen) to the
 

spinal cord is blocked resulting in injury and destruction to the nerve fibers.

12 Myelitis is inflammation of the spinal cord.
 13 Tracheostomy is a surgical procedure that creates an opening in the neck into the trachea (windpipe) to help get air
 

to the lungs.
 

VA Office of Inspector General 4 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Inspection Results 

Issue 1: Quality of Post-Operative Care 

We did not substantiate the allegation that an epidural catheter caused the patient’s 

paralysis. We found no irregularities in the catheter’s placement and the post-operative 

MRI revealed no findings suggestive of injury from the catheter. 

The medical record shows that the patient was stable post procedure and transported 

directly to the ICU for post anesthesia recovery. The ICU Post Anesthesia Recovery note 

shows that the patient was moving all four extremities at 4:40 p.m. There was no 

documentation of the patient’s neurological status again until 6:45 a.m. the next day 

when the anesthesiologist noted that the patient could not move his legs. 

We reviewed the ICU nursing flow sheets and found that the patient was hypotensive in 

the ICU for a period of 6 hours. We reviewed the BPs documented by the nurse from 

7:00 p.m. on the day of surgery to 1:00 a.m. the next morning. Although the order was to 

adjust the phenylephrine to the MAP, we found no documentation of MAPs on the 

nursing flow sheet. The nurse reported that MAPs were observed on the telemetry 

monitor and they were not required to document the MAP readings on the flow sheet. In 

order to determine the MAP during this time period, we calculated the MAPs using the 

standard formula.14 We found 15 (65 percent) of the 23 MAPs were < 60. The BPs, to 

include MAPs, are displayed below in Figure 1. 

Figure 1. Systolic, mean, and diastolic blood pressures, mm Hg 

120 

110 

100 

90 

80 

70 

60 

50 

40 

30 

20 

6:00AM 5:00AM 4:00AM 3:00AM 2:00AM 1:00AM 12:00AM 

11:00PM 1:000PM 9:00PM8:00PM 7:00PM 6:00PM 5:00PM 4:00PM 

We determined that the ICU nurse was aware at 7:00 p.m. that the patient’s BP was 

dropping, but did not call the resident until 9:00 p.m. The patient’s MAP was 

continuously < 60 between 11:00 p.m. and 1 a.m., ranging from 46 to 57. The nurse did 

not inform the resident of the patient’s condition until 12:50 a.m. Prior to notifying the 

resident, the nurse documented that the phenylephrine IV was adjusted every 15 minutes; 

14 MAP = [2 x diastolic + systolic] / 3 for example: 70/48 = (48x2+70)/3=55.3. 

VA Office of Inspector General 5 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

however, each titration was not documented. Therefore, the period of time the 

medication was adjusted, or how much of the medication the patient received could not 

be determined. 

We also determined there was a delay in administering the phenylephrine. The nurse 

received a verbal order from the resident for the phenylephrine at 9:00 p.m. We did not 

find any documentation that the order was initiated. The nurse received another order for 

phenylephrine from the attending physician at 9:35 p.m. We could not determine when 

the medication was started, only that it was infusing at 10:30 p.m. 

Issue 2: Nursing Documentation 

We reviewed ICU nursing documentation and found that patient assessments were not 

completed according to local policy.15 The policy requires that an initial assessment is 

completed on admission and reassessments every 2 hours or as needed based on patient’s 

individual needs and change in level of care and diagnosis. The policy also requires an 

assessment to evaluate the response to care. We found that the ICU nurses completed the 

initial assessment and reassessments but they were incomplete. The assessments did not 

include documentation of the epidural catheter, neurological assessments, documentation 

of IV medications (phenylephrine), and the MAPs used as a measure to adjust the 

phenylephrine. The nurse manager acknowledged that documentation had been an 

ongoing problem and needed improvement. 

Local policy16 requires that telephone orders be accepted only in urgent circumstances 

and that the registered nurse enter verbal orders into the computerized patient record 

system (CPRS). The nurse received a verbal order for phenylephrine at 9:00 p.m. and a 

verbal order to discontinue the Lactated Ringer’s IV bolus at 9:35 p.m. but did not enter 

the orders into CPRS. 

Issue 3: Reporting of Adverse Events 

Medical center managers did not conduct a review of the post-operative paralysis until 

after they were notified by OIG of the complainant’s allegations. VHA requires17 

medical centers to conduct a review of certain adverse events for the purpose of quality 

improvement. Although the case was not reported at the time it occurred, managers took 

action once they were made aware of the incident. Managers determined that the 

patient’s blood pressure dropped while in the ICU and was not treated as aggressively as 

it should have; however, it was not determined whether the low blood pressure was the 

cause of the patient’s paralysis. The medical center later disclosed the event to the 

family. 

15 Policy 11-12, Assessment and Care of Patients, June 2008.
 16 Policy 119-01, Physician Orders, December 14, 2007.
 17 VHA Directive 2010-025, Peer Review for Quality Management, June 2010.
 

VA Office of Inspector General 6 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Conclusions 

We did not substantiate that an epidural catheter insertion was the cause of the patient’s 

paralysis. We found that the catheter insertion was performed according to standard 

procedures, and the radiology report did not reveal evidence of trauma from insertion of 

the catheter. However, we did find that prolonged hypotension may have contributed to 

spinal cord infarction and subsequent paralysis. We concluded that the patient’s blood 

pressure was poorly monitored while he was in the ICU, and actions taken to treat his 

hypotension were inadequate. The medical center obtained peer review assessments of 

the care provided in the case described. 

During our review, we identified two areas that needed improvement. First, ICU staff 

need to improve patient assessments and corresponding documentation. Second, senior 

leaders need to ensure that processes are in place for reporting and evaluating adverse 

events. Senior leaders were not informed of this incident until notified by OIG of the 

complaint; consequently, fact finding reviews were not initiated. Without appropriate 

reporting and evaluation of patient incidents, the medical center may miss opportunities 

to improve patient care and processes. 

Recommendations 

Recommendation 1. We recommended that the Medical Center Director ensure that 

patients in the ICU are assessed appropriately and that patient care activities are 

consistently documented. 

Recommendation 2. We recommended that the Medical Center Director ensure that 

processes are in place for reporting and evaluating adverse events. 

Comments 

The VISN and Medical Center Directors concurred with our findings and 

recommendations (see Appendixes B and C, pages 9–15 for the full text of their 

comments). The implementation plans are acceptable, and we will follow up on the 

planned actions until they are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 7 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Appendix A 

Table 1. Alleged OR Incidents with OIG Findings and Conclusions.

Date Allegation Finding Conclusion 

August 31, 2009 A patient bled while on the OR table and 

later died. 

We reviewed the medical record and 

found that the patient did not have 

surgery on August 31, 2009. In addition, 

the patient was still living. 

Not substantiated 

July 2010 A block was performed on the wrong 

extremity while four anesthesia staff 

members were present in the room. 

We reviewed the operating room report 

and found that the surgical site was 

marked and timeout was performed to 

verify correct patient and site. We found 

no evidence that a block was performed 

on the wrong extremity. 

Not substantiated 

September 2010 A scrub technician was intoxicated in the 

OR. 

We did not have enough information to 

pursue this allegation. 

Neither confirmed nor 

refuted 

September 14, 2010 The wrong local anesthetic was given to 

the surgeon to inject into the toe of a 

patient resulting in possible necrosis. 

We reviewed the patient’s medical record 

and did not find evidence of necrosis. 

Not substantiated 

November 17, 2010 Staff failed to perform a count after a 

microlaryngoscopy, resulting in the 

patient being x-rayed to determine if any 

surgical items were left in the patient. 

We found that the procedure does not 

involve surgical items that could be left in 

the patient and that an x-ray is standard 

protocol after the procedure. 

Not substantiated 

Unknown A physician was reported falling asleep 

during work hours, and was forced to 

have a sleep study. 

We did not pursue the allegation because 

the medical center had taken appropriate 

action. 

Neither confirmed nor 

refuted 

VA Office of Inspector General 8 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Appendix B 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: April 26, 2011 

From: Director, South Central VA Health Care Network (10N16) 

Subject: Healthcare Inspection – Post-Operative Paralysis, Overton

Brooks VA Medical Center, Shreveport, Louisiana

To: Director, San Diego Office of Healthcare Inspections (54SD) 

Thru: Director, Management Review Service (10B5) 

1. I have reviewed the report and concur with the 

recommendations and the stated action plans. 

2. If you have any questions regarding the report, please 

contact Mary Jones, HSS [Health System Specialist] at 

(601) 206-6974. 

(original signed by:) 

George H. Gray, Jr., FACHE
 

Director, South Central VA Health Care Network (10N16)
 

VA Office of Inspector General 9 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Appendix C 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 April 22, 2011 

From:	 Director, Overton Brooks VA Medical Center (667/00) 

Subject:	 Healthcare Inspection – Post-Operative Paralysis, Overton

Brooks VA Medical Center, Shreveport, Louisiana

To:	 Director, South Central VA Health Care Network (10N16) 

1. I concur with the findings and recommendations of this Office of 

Inspector General report. The Overton Brooks VAMC appreciates the 

external perspective provided by this report. The Overton Brooks 

VAMC’s reply outlines the actions taken in response to these 

findings. If there is any additional information required, you may 

contact Susan Lott, RN, Acting Chief, Performance Improvement 

Service at (318) 990-5125. 

(original signed by:) 

Kathleen Fogarty, FACHE
 

Director, Overton Brooks VA Medical Center (667/00)
 

VA Office of Inspector General 10 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Director’s Comments
	

to Office of Inspector General’s Report
	

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 1. We recommended that the Medical Center Director 

ensure that patients in the ICU are assessed appropriately and that patient 

care activities are consistently documented. 

Concur Target Completion Date: December 30, 2011 

Medical Center’s Response:

As a result of this occurrence, the Overton Brooks VA Medical Center 

implemented a series of refresher courses or “Boot Camps” for nursing 

staff to improve the quality of care administered and to ensure that our 

veterans receive the appropriate care based upon their assessed needs. 

These educational boot camps cover various topics including: care of a 

patient with an epidural catheter; reemphasis of the basic expectations and 

guidelines of patient care in the ICU and step down units; mock code 

training; respiratory distress scenarios; cardiogenic shock scenarios; and a 

future course in hemodynamics. Full description and training dates are 

attached below. Additionally, the Overton Brooks VA Medical Center 

developed and implemented a new flow sheet which improves our 

documentation of the status of the patient and assists in ensuring 

compliance with local policies, VA National Policies, and The Joint 

Commission (TJC) standards. 

The following actions have been taken to improve care in the ICU and Step 

Down units: 

RCA Actions Completed Follow-up

1. Overton Brooks VA Medical Center 

implemented a new flow sheet for 

improved documentation of patient status 

and assist in ensuring compliance with 

local policies, VHA National Policies, and 

The Joint Commission (TJC) standards. 

Completed 

document template 

and implemented 

March 24, 2011 

Monthly record reviews 

to ensure staff utilization 

and accuracy. Report 

monthly to PI Committee 

and Nursing Leadership 

Committee. 

VA Office of Inspector General 11 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

2. All ICU staff completed an initial Post- Completed: Follow up: Staff not 

Anesthesia Care Unit and surgical March 30, 2011 completed will do so 

specialty specific competency and skills 24/26 =92.3% within 30 Days of return 

validation one nurse is to duty. 

deployed/one on 

extended leave 

3. Staff additionally read an article on the Completed: Follow up: Staff not 

care of a patient with an epidural catheter April 25, 2011 completed will do so 

and took a competency test based on the 40/41= 97.6% within 30 Days of return 

information given. One nurse to duty. 

deployed 

4. Staff are attending “Boot Camps” Completed: Follow up: Staff not 

which will be provided in five (5) March 4, 2011 completed will do so 

Sessions to reinforce competencies: 40/41= 97.6% within 30 Days of return 

The first “Boot camp” was in One nurse is to duty. 

January 2011 and covered the guidelines, deployed 

standards, and expectations for care of 

patients in the ICU. Including training on 

new ICU flow sheet 

5. The second “Boot camp” covered Completed: Follow up: Staff not 

emergency situations which was in March 7, 2011 completed will do so 

February 2011 and covered: 40/41= 97.6% within 30 Days of return 

 BLS [basic life support] One nurse is to duty. 

 Use of Lifepack 20 for defibrillations, deployed 

cardioversions and pacing 

 Location of supplies on crash cart 

 Autopulse 

 Technique for insertion of intraosseous 

needle 

6. The third “Boot Camp” covered Completed: Follow up: Staff not 

respiratory distress which was in March 30, 2011 completed will do so 

March 2011 and covered: 39/41=95.1% within 30 Days of return 

 Ventilators- how to recognize and One nurses is to duty.
 

manage alarms
 deployed and one 

 Use of IVAC on extended leave 

 How to draw blood cultures 

 Use of restraints-proper alternatives 

and documentation Intubation 

setup/confirmation 

 Rapid sequence intubation testing 

 Care of patient on mechanical 

ventilator (alarms, troubleshooting, 

VAP bundle) 

 Continuous sedation while on 

ventilator (demonstrated setup on IV 

VA Office of Inspector General 12 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

pump and score pain using nonverbal 

pain scale) 

 Monitoring and documentation of 

level of sedation using RASS scale 

 Central line setup for insertion 

 Chest tube setup and care (in scenario 

patient develops pneumothorax after 

central line insertion) 

 Maintenance of chest tubes 

 Completed and passed test on rapid 

sequence intubation and ventilators. 

7. The fourth “Boot Camp” will be held Completed Date: Pending Completion 

the end of April 2011 and will cover Boot Camp will be 

IABP’s. By the end of this session the held April 26 – 

staff will have taken an online class and April 27 

completed an associated test. 

Additionally, they will receive hands on 

training from our IABP vendor 

representative. 

8. The final “Boot Camp” will be held in Boot Camp will be Pending Completion 

May and will focus on: held in May 2011 

 Hemodynamics. 

 This session will cover Femstop, Porta-Cath, Alaris Pumps and set up for 

PCA, 

 Med Sled, 

 Heparin protocol, and 

 Competency Test covering 

hemodynamics and Duotube. 

9. Nursing Leadership will ensure a Pending 

comprehensive test be administered to the Completion 

attendees to ensure understanding of the 

information or training provided. 

10. Future Boot Camp plans are being Pending 

finalized. The plan is for the majority of Completion 

the information to be incorporated into 

new ICU and Step Down nurse employee 

orientation, with additional classes being 

held throughout the year on low volume 

high impact topics. 

VA Office of Inspector General 13 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Recommendation 2. We recommended that the Medical Center Director 

ensure that processes are in place for reporting and evaluating adverse 

events. 

Concur Target Completion Date: December 30, 2011 

Medical Center’s Response:

Upon discovery of this event, a Root Cause Analysis (RCA) Team was 

chartered. The charter for this RCA was to review events related to this 

occurrence regarding the reporting aspects, and to determine methods by 

which to increase requirements for and awareness of reporting of adverse 

events. The following were actions taken by the medical center as a result 

of the RCA: 

VA Office of Inspector General 14 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Revise Patient Safety Program policy to 

require all who witness an adverse event 

to report the event to Patient Safety/ 

ensure that the event is reported to Patient 

Safety. 

RCA Actions

January 5, 2011 

Completed

Completed 

Follow-up

Revision of Attachment C of Patient 

Safety Program, “Incident Occurrences” 

to include a simplified algorithm outlining 

reporting/notification process. 

January 5, 2011 Review a 20% sample 

of all incident reports 

for April, May, and 

June 2011 to ensure 

proper notification 

processes followed – 

Due July 2011 

Posting of simplified Algorithm in clinical 

areas. 

April 2, 2011 Random survey of 

staff regarding 

knowledge of 

algorithm – Due 

August 2011 

A direct link to the incident report form 

with inclusion of Patient Safety Reporting 

Hotline phone number added the Medical 

Center Intranet homepage. 

Education of all staff regarding what 

incidents/adverse events are, requirement 

January 31, 2011 

MCD staff– February 

28, 2011 

Review the number of 

times direct link 

accessed for April, 

May, and June 2011 to 

determine efficacy – 

Due July 2011 

Patient Safety 

Manager to review for 

of algorithm and use of direct link. 

for reporting of events and close calls, 

how to report events and close calls, use 

Acting Associate 

Director staff– March 

30, 2011 

Acting Nurse Executive 

staff– April 14, 2011 

COS staff– February 3, 

2011 

throughout fiscal year 

2011 

percentage increase in 

incident reporting 

All ICU nursing staff and nurse mangers 

have been educated on where the incident 

form (VAF10:2633) is located and how to 

use them appropriately. 

Completed: 

April 1, 2011 

40/41= 97.6% 

One nurse is deployed 

Staff not completed 

will do so within 

30 days of return to 

duty 

On March 9, 2011, OR staff participated 

in a one day “Safety Stand Down.” The 

OR staff reviewed proper safety 

procedures and what could happen if these 

procedures are not followed correctly. 

The Stand Down was conducted by the 

VISN CMO and VISN Lead Surgeon. 

Sixteen OR Staff 

participated, while the 

other staff where still 

doing their cases. The 

information was shared 

and all were made aware 

of the situation and the 

material covered. 

VA Office of Inspector General 15 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Appendix D 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Acknowledgments	 Deborah Howard, RN, Project Leader 

Stephanie Hills, RN, Team Leader 

Sheila Bezak, RN 

Elizabeth Burns, MSSW 

Jerome Herbers, MD 

Sandy Khan, RN 

Derrick Hudson 

VA Office of Inspector General 16 
Post-Operative Paralysis, Overton Brooks VA Medical Center, Shreveport, Louisiana 

Appendix E 

Report Distribution
	

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, South Central VA Health Care Network (10N16) 

Director, Overton Brooks VA Medical Center (667/00) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Mary L. Landrieu and David Vitter 

U.S. House of Representative: Rodney Alexander, Charles W. Boustany, Jr., William 

“Bill” Cassidy, John Fleming, Jeffrey Landry, Cedric Richmond and Steve Scalise 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 17