VA hospital nurse mixes up resuscitation order, patient dies

As a Houston, Texas medical malpractice lawyer, I have represented many clients in medical negligence or wrongful death cases arising from hospital care provided after the surgery.

Recently, the Office of the Inspector General released report critical of a VA Hospital’s handling of a patient’s care after a bypass surgery. The patient was admitted to the hospital for surgery to address leg pain from a blocked artery.

While he was recovering from the surgery, the patient experienced chest pain and nausea. By the time the nurse returned to the room with an electrocardiogram machine, the patient was unresponsive with abnormal breathing.

The nurse told other healthcare providers that the man status was “do not resuscitate.” Unfortunately, the nurse was wrong, and the patient died.

The Inspector General report found that this incident was the third time in four years that the same nurse was ”involved in significant monitoring deficiencies in-risk patients.” The nurse indicated that he was caring for two other patients and became confused about the resuscitation orders.

I find this case sad and alarming on multiple levels.

First, healthcare providers, including both doctors and nurses, must be aware of a patient’s resuscitation status. In the event that the status is unknown, then the standard of care requires them to provide resuscitation efforts in the event of cardiac or respiratory arrest.

Second, any time that hospital administrators are aware of sub-standard care on the part of a doctor or nurse, they are responsible for removing the healthcare provider from patient care until remedial measures can be taken. This would include the nurse or doctor attending educational offerings and then demonstrating competence to the satisfaction of hospital administration or the credentialing committee. To ignore repeated instances of poor care needlessly endangers patient safety.

Third, hospitals experiencing this type of issue should conduct a root cause analysis to learn exactly what errors occurred, and how to avoid them. After this incident, the VA hospital implement a new policy requiring a nurse or supervisor to independently verify resuscitation orders in an emergency situation.

What you can do

Having a family member or loved one with a patient at all times during hospitalization can help to avoid medical errors, such as the terrible outcome in this VA hospital case. While doctors and nurses are certainly expected to provide competent and compassionate care, the input and advocacy of family members provide an extra layer of protection.

In addition, I recommend that patients think ahead and hire an attorney to help them prepare an advance directive and living will that identify the patient’s wishes in the potential code or end-of-life situation. Once these documents are executed, the patient should always provide a copy to the nursing staff upon any hospital admission.

If you or someone you care for has been seriously injured as a result of medical malpractice in a hospital or other setting, call the experienced attorneys at Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.


Robert Painter is an experienced medical malpractice and wrongful death lawyer at Painter Law Firm PLLC, in Houston, Texas. He focuses his practice on representing patients and family members in serious injury and death cases.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.