A patient at the Rocky Mountain Regional VA Medical Center in Aurora died last year after a hospital staff member turned off their notification device alerting them to the veteran’s rapidly declining condition.
An investigation by the VA’s Office of Inspector General found, in spring 2023, a telemetry medical instrument technician missed several red alarms concerning the patient’s oxygenation levels. By the time clinicians arrived, the individual was “unresponsive and pulseless,” inspectors found.
Telemetry remotely measures and collects clinical data, including respiratory rate, pulse rate, oxygen saturation and blood pressure. Technicians receive alerts depending on patients’ conditions and are supposed to alert nurses in the event of rapid changes.
Hospital staff told investigators that this technician regularly changed patient alarm settings and placed communication devices on “do not disturb” for long periods of time.
Leadership in September 2022 became aware of technicians not adhering to alarm monitoring expectations, the report notes. Brass at that time provided education in staff meetings and issued a letter of expectations. A nurse manager told investigators they had completed audits of alarm monitoring a few times a month but could not provide any records to investigators.
Hospital staff did not file a patient safety report for the patient death — an omission one manager called “extremely surprising”, inspectors said.
The inspector general expressed “concern that the lack of clinical alarm management oversight could result in an increased risk for the occurrence of patient safety events.”
Investigators concluded that the delay in alarm notification with this patient “could have resulted in serious injury to the patient and possibly contributed to the patient’s death.”
Still, due to patient comorbidities and complexity of care, inspectors could not determine if the failures impacted the patient’s clinical care. The VA, meanwhile, didn’t tell the family what happened.
The report documented a second instance in which a patient experienced a cardiac event, but clinicians were unaware for hours due to the patient’s alarm being turned off.
Leadership, after the incidents, removed the two technicians from patient care.
In 2013, The Joint Commission, a patient safety organization, noted the risks of “alarm fatigue” — when clinicians turn off or fail to respond to alarm signals. The Commission stated that these systems, if not properly managed, “can compromise patient safety.”
Hospital leaders, the organization recommended, should make alarm safety a hospital priority.
The VA, in a statement to The Post, said they “regret the circumstances surrounding the care of these veterans.” The agency pledged to take “significant actions to improve our telemetry and alarm monitoring processes as a result of this review.”
Staff have revised their telemetry policy and agreed to regular monitoring and audits to ensure compliance. Patient safety managers, meanwhile, are tracking all patient safety reports to ensure monitoring and accountability, Janelle Beswick, a regional VA spokesperson, said in an email.
The medical center’s risk manager will now track and categorize adverse events and make these findings available to the Aurora VA’s executive leadership team, she said.
Amir Farooqi, the interim director of the VA Eastern Colorado Health Care System, said Wednesday during an employee town hall that this is the final inspector general report the Aurora VA expects for a while.
“That final bandaid has been ripped off,” he said. “This is an opportunity for us to heal.”
The inspector general’s findings are just the latest in a series of scathing reports indicting the Eastern Colorado VA’s former leadership.
In June, the OIG found the Aurora VA paused heart surgeries for more than a year in 2022 and 2023 because they didn’t have the staff to care for those patients after the procedures — but never told the Veterans Health Administration, as required.
A second report released that month found leadership created a “culture of fear” among hospital staff that compromised patient safety.
The Denver Post reported last year that the hospital’s prosthetics department was instructing employees to cancel veterans’ orders to clear a large backlog. The VA later confirmed The Post’s reporting.
This spring, the hospital canceled hundreds of surgeries after finding mysterious black flecks on its surgical equipment. The VA resumed all surgeries this week.
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