{"database": "press", "table": "releases", "rows": [["https://debbiedingell.house.gov/media-center/press-releases/dingell-walberg-seek-information-ann-arbor-va-efforts-respond-fatal-do", "Dingell, Walberg Seek Information from Ann Arbor VA on Efforts to Respond to Fatal Do-Not-Resuscitate Mistake", "2017-11-09", "2017", "2017-11", "Democrat", "House", "MI", "Debbie Dingell", "D000624", "debbiedingell.house.gov", null, null, "legacy", "WASHINGTON, D.C. \u2013 Following the tragic death of a veteran at the VA Ann Arbor Healthcare System after confusion over a Do Not Attempt Resuscitation (DNAR) order, U.S. Representatives Debbie Dingell (MI-12) and Tim Walberg (MI-07) today sent a letter to VISN 10 Network Director Robert McDivitt and VA Ann Arbor Acting Director Andrew Pacyna requesting information about all efforts being taken to implement recommendations made by the Veteran\u2019s Affairs Office of Inspector General (OIG) to prevent a similar tragedy in the future.\u00a0\n\u201cIt is critical that we fully understand the actions being taken to implement the OIG\u2019s recommendations so that we can ensure that a similar tragedy never happens again,\u201d the Representatives wrote. \u201cPatient care and safety must be the top priority at the VA Ann Arbor Healthcare System. Our veterans have made great sacrifices for our nation, and we have an obligation to make sure they are properly cared for during all treatment.\u201d\nThe OIG report released this week made six recommendations to the VISN Director, including requiring staff to immediately verify resuscitation status of patients; ensuring that DNAR and the Cardiopulmonary Resuscitation orders align with one another; and improving staff training, among other recommendations.\u00a0\u00a0\n\u201cWhile you have concurred with each of these recommendations we would request a full response regarding all efforts being taking to implement these potentially lifesaving recommendations for our veterans,\u201d the Representatives continued. \u201cWe would also request an estimated timeline for meeting these recommendations and to receive regular updates throughout the process.\u201d\nThe full letter can be read here and below.\u00a0\nNovember 9, 2017\nMr. Robert McDivitt\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Mr. Andrew Pacyna\u00a0 \u00a0 \u00a0  \n\tNetwork Director\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Acting Director\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0  \n\tVeterans Integrated Service Network 10\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 VA Ann Arbor Healthcare System  \n\t11500 Northlake Drive, Suite 200\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a02215 Fuller Rd\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0  \n\tCincinnati, OH 45249\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Ann Arbor, MI 48105\nDear Director McDivitt and Acting Director Pacyna:\nThis letter is regarding the tragic death of a veteran at the Ann Arbor VA Medical Center and a subsequent report by the U.S. Department of Veterans Affairs Office of Inspector General (OIG).\u00a0 The report found that a nurse mistakenly thought the veteran had a Do Not Attempt Resuscitation (DNAR) order and therefore did not attempt to revive the veteran who then passed away.\u00a0 The OIG recently issued a report on this tragedy and made several important recommendations.\u00a0 It is critical that we fully understand the actions being taken to implement the OIG\u2019s recommendations so that we can ensure that a similar tragedy never happens again.\u00a0\nAccording to the OIG report, several factors contributed to the confusion surrounding the veteran\u2019s DNAR status, but it is clear that there was no standardized process to manage the communication of a patient\u2019s resuscitation status between nurses and doctors. It is even more troubling to learn that the existence of vulnerabilities related to confirming resuscitation status\u2014particularly during worsening patient conditions\u2014were identified by VA leadership a year prior to this incident and no remedial measures were taken.\u00a0\nThe OIG has made six specific recommendations, including requiring staff to immediately verify resuscitation status of patients; ensuring that DNAR and the Cardiopulmonary Resuscitation orders align with one another; improving staff training and education; obtaining an independent external review; and other administrative recommendations.\u00a0 While you have concurred with each of these recommendations we would request a full response regarding all efforts being taking to implement these potentially lifesaving recommendations for our veterans.\u00a0 We would also request an estimated timeline for meeting these recommendations and to receive regular updates throughout the process.\u00a0\nPatient care and safety must be the top priority at the VA Ann Arbor Healthcare System.\u00a0 Our veterans have made great sacrifices for our nation, and we have an obligation to make sure they are properly cared for during all treatment.\u00a0 Thank you for your attention on this important matter and for the swift actions already being taken to ensure our veterans are receiving the highest level of care moving forward.\n  \n\tSincerely,", 1, "2026-03-30T12:14:52Z", "2026-03-30T12:14:52Z"]], "columns": ["url", "title", "date", "year", "month", "party", "chamber", "state", "member_name", "bioguide_id", "domain", "scraper", "source", "date_source", "text", "has_text", "collected_at", "updated_at"], "primary_keys": ["url"], "primary_key_values": ["https://debbiedingell.house.gov/media-center/press-releases/dingell-walberg-seek-information-ann-arbor-va-efforts-respond-fatal-do"], "units": {}, "query_ms": 1.5076880808919668, "source": "dwillis/congress-press", "source_url": "https://github.com/dwillis/congress-press", "license": "MIT", "license_url": "https://github.com/dwillis/congress-press/blob/main/LICENSE"}