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Veteran Dies Due to Nurse Mistakingly Thinking Patient Had Do Not Resuscitate Order

We have all heard the expression “good enough for government work.”  Generally, it is offered as a humorous twist on some government service absurdity. That ethic is not always amusing, however.  If the mail carrier consistently delivers mail to the wrong house that’s a problem, but no one is going to die.  When a nurse confuses the code status of his or her patients then people can die.  As reported by Law360 that is exactly what happened at the VAMC in Ann Arbor, Michigan. After an operation, a veteran had difficulty breathing and then stopped breathing altogether.  The nurse mistakenly thought the patient had a DNR (do not resuscitate) order so she just let him go. The veteran was actually “full code” status, meaning they needed to do everything they could to save him.


The VA Inspector General issued a report finding systemic errors.  The hospital lacked a “standardized process” for communicating this important information.  What was worse is that the hospital had identified this specific problem a year before this veteran was killed.  It didn’t correct it.  Someone died.  No surprise.