Date Issued
|
Report Number
21-01524-43
|
Topics: Patient Safety
All Reports
Date Issued
|
Report Number
21-01049-39
|
Topics: Patient Safety
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
The West Palm Beach VA Medical Center Director evaluates clinical disclosure practices and takes action as warranted to ensure compliance with Veterans Health Administration Directive 1004.08.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director ensures that Patient A’s and Patient B’s episodes of care are reviewed to determine if an institutional disclosure is needed per Veterans Health Administration Directive 1004.08 and takes action accordingly.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director evaluates facility compliance with Veterans Health Administration Directive 1004.08 regarding institutional disclosure processes and takes corrective actions as needed.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director explores reasons Joint Patient Safety Reports were not entered for some adverse events experienced by Patient A and Patient B and takes action accordingly to ensure compliance with Veterans Health Administration Handbook 1050.01.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director confirms that the Surgical Workgroup’s meeting minutes document oversight of the Surgical Service Morbidity and Mortality Conference by including issues discussed, conclusions, actions, recommendations, evaluations, and follow up in accordance with Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director identifies reasons a planned peer review was not completed in accordance with Veterans Health Administration Directive 1190 and takes corrective action as indicated.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director reviews processes for evaluation of urologists’ privileging forms and takes action as necessary to ensure compliance with Veterans Health Administration Handbook 1100.19 and Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
Date Issued
|
Report Number
21-01695-38
|
Topics: Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director reviews roles and responsibilities for interdisciplinary treatment team members and the process for communication of plans and recommendations from all clinical team members and takes action as indicated.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director ensures clinical staff follow established policy to alert clinical team of pertinent care changes by using the additional signer functionality or other methods of communication.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/30/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned occupational therapy provider involved in the discharge planning for the patient and takes follow-up action as indicated.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the attending physician involved in the discharge planning for the patient and takes follow-up action as indicated.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned social worker involved in the discharge planning for the patient and takes follow-up action as indicated.
Date Issued
|
Report Number
20-03700-35
|
Topics: Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/16/2022
The Raymond G. Murphy VA Medical Center Director ensures supervising providers oversee all clinical decisions made by residents and the oversight is reflected within the documentation, including telephone notes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/13/2024
The Raymond G. Murphy VA Medical Center Director ensures supervising providers establish a reliable way to receive alerts for the results of all tests ordered by residents.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director ensures that Primary Care and Specialty Care staff coordinate care for shared patients and evaluates the need for Outpatient Care Coordination Agreements.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director ensures that patient, family, or staff concerns regarding delay in diagnosis are entered into the patient safety reporting system and appropriate follow-up is completed.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director coordinates a comprehensive review of the patient’s care, takes action as warranted, and reconsiders an Institutional Disclosure.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/15/2023
The Raymond G. Murphy VA Medical Center Director ensures consistency between the relevant prior radiological images reviewed when staff radiologists and contract teleradiologists interpret imaging scans for Raymond G. Murphy VA Medical Center patients.
Date Issued
|
Report Number
21-01682-25
|
Topics: Mental Health
● Care Coordination
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The Southern Oregon Rehabilitation Center and Clinics Director conducts an assessment to ensure all applicable elements of the Southern Oregon Rehabilitation Center and Clinics continuing care plan template are addressed when discharging residents from the Mental Health Residential Rehabilitation Treatment Program and takes action as warranted.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/17/2023
The Southern Oregon Rehabilitation Center and Clinics Director ensures discharges of residents from the Mental Health Residential Rehabilitation Treatment Program occur during regular business hours in accordance with Veterans Health Administration Directive 1162.02.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Southern Oregon Rehabilitation Center and Clinics Director reviews Southern Oregon Rehabilitation Center and Clinics transportation policies to ensure alignment with Veterans
Health Administration transportation directives, including management of the transport of residents with behavioral flags.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The Southern Oregon Rehabilitation Center and Clinics Director develops a process to ensure an updated medical evaluation is conducted should the admission team be notified of a change in
medical status that occurs after a veteran’s initial admission screening medical evaluation but prior to admission to the Mental Health Residential Treatment Program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Southern Oregon Rehabilitation Center and Clinics Director completes a systematic review of residents’ falls in the shower area on the Mental Health Rehabilitation Residential Program units and takes action as warranted.
Date Issued
|
Report Number
21-00274-289
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Director evaluates and determines additional reasons for noncompliance and ensures the Surgical Workgroup conducts a monthly review of surgical deaths.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/29/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members participate in disruptive behavior event reviews.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/29/2022
The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.
Date Issued
|
Report Number
21-00553-285
|
Topics: COVID-19
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Great Lakes Health Care System Director evaluates whether administrative action is warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at the VA Illiana Health Care System, and takes action, as appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director ensures the plan to monitor and track face mask wearing by staff at the community living center adheres to current Centers for Disease Control and Prevention guidance, is ongoing, results are monitored, and action plans are implemented as warranted.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director confirms that all community living center staff identified as requiring respiratory protection are fit tested, trained, and have ready access to respiratory devices.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director ensures a plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding staff with known community exposure to COVID-19, and monitors for compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding community living center residents with known exposure to individuals diagnosed with COVID-19, and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director ensures operability and use of the bed management system for tracking completion of room cleaning.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/12/2022
The VA Illiana Health Care System Director oversees the completion and implementation of a policy for administering aerosol-generating procedures during the COVID-19 pandemic that adheres to Centers for Disease Control and Prevention guidance, and monitors compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director evaluates the organizational approach for notifying managers of updated Veterans Health Administration policies and guidance for monitoring actions taken to ensure compliance with new requirements.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/13/2022
The VA Illiana Health Care System Director reinforces facility staff understanding of Veterans Health Administration guidance related to community living center practices, including group activities, disseminated during emergent events such as a pandemic and maintains oversight of community living center leaders’ implementation of such guidance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director directs community living center leaders to complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director evaluates the community living center standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to ensure that it provides guidance with specific actions for staff to take when a resident tests positive for COVID-19.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director verifies that COVID-19 testing for community living center residents and staff occurs as required for both routine surveillance and in response to confirmed cases of COVID-19.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/13/2022
The VA Illiana Health Care System Director confirms that the community living center COVID-19 standard operating procedure clearly communicates the process, including roles and responsibilities, for notification of a resident’s change in condition or room assignment and communicates the plan to all community living staff.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director executes a process to ensure that the facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the community living center, and when identified, creates a plan to mitigate and manage risk.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director directs those conducting the facility’s after-action review of the community living center outbreak to include input from frontline community living center staff and takes action as necessary.
Date Issued
|
Report Number
21-01304-275
|
Topics: COVID-19
● Patient Safety
● Appointment Scheduling and Wait Times
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Fayetteville VA Coastal Health Care System Director ensures that dietitians comply with conducting and documenting comprehensive nutrition assessments, including patients’ weight measurements, changes to nutrition diagnosis, chewing and swallowing abilities, and calorie and protein requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director ensures there is consistent communication and coordination of care between the Patient Aligned Care Team registered nurses and the primary care providers.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director provides guidance on care coordination between outpatient dietitians and primary care providers when a higher level of nutrition intervention is required.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/2/2023
The Fayetteville VA Coastal Health Care System Director monitors that follow-up appointments for dietitians are scheduled as ordered.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/31/2025
The Fayetteville VA Coastal Health Care System Director ensures that non-VA dental appointments are scheduled within recommended time frames by the Community Care program scheduling staff and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director evaluates the COVID-19 scheduling practices and the impact of telephone appointments on the patient’s care.
Date Issued
|
Report Number
21-01677-259
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The Under Secretary for Health clarifies the extent and content of documentation that should be included when circumstances require that a clinical disclosure be entered into the electronic health record.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/15/2022
The Under Secretary for Health evaluates whether there should be a process for clinical provider(s) to communicate back to the Clinical Review Team when changes in patient health status indicate the need for consideration of institutional disclosures, and takes action as warranted.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/17/2022
The Veterans Health Care System of the Ozarks Director implements a plan for completion of amended pathology reports for cases identified with level 2 pathology reading errors that is consistent with VHA Handbook 1106.01.
Date Issued
|
Report Number
20-02907-254
|
Topics: Mental Health
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/31/2022
The Tuscaloosa VA Medical Center Director reviews informed treatment consent processes for the Inpatient Mental Health Unit and Community Living Center, confirms staff understanding of required processes, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director ensures decision-making capacity evaluation completion and documentation, as required by Veterans Health Administration policy, and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/14/2022
The Tuscaloosa VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of Alabama commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director ensures adherence to Tuscaloosa VA Medical Center policies regarding against medical advice discharge procedures, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director consults with VA National Center for Ethics in Healthcare and reconsults the Office of General Counsel as needed to evaluate the appropriateness of the patient’s assigned surrogate decision-maker, and takes action as warranted.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The Tuscaloosa VA Medical Center Director ensures staff completion of required patient advocate reporting and tracking processes, and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director evaluates the Community Living Center staff’s management of the patient’s correspondence request, including the Integrated Ethics consultation, and takes action as warranted.
Date Issued
|
Report Number
21-00265-231
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/5/2023
The Associate Director for Patient Care evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Date Issued
|
Report Number
20-01917-242
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director ensures that providers receive education regarding the management of alcohol withdrawal and delirium tremens, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director makes certain providers consider patients’ underlying cardiac risk prior to the order of haloperidol.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/13/2022
The Tomah VA Medical Center Director conducts a comprehensive review of the patient’s cardiopulmonary resuscitation event to determine potential causes of failed oxygen delivery including systemic root causes and performance deficiencies, and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted and takes action.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director implements actions recommended by the Out of Operating Room Airway Management workgroup, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director evaluates staff adherence to the Tomah VA Medical Center Policy MS-25, Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) Protocol and the Standard Operating Procedure for Nursing Procedure, Symptom Triggered CIWA-Ar Protocol, and takes action to ensure compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/17/2022
The Tomah VA Medical Center Director ensures inpatient medical unit providers and nursing staff compliance with patient restraint management, as required by to the Tomah VA Medical Center Policy, PCS-03, Restraint and Seclusion Use.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director monitors provider compliance with Tomah VA Medical Center Policy MS-06, Admission Criteria for Acute Medicine Unit.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director consults with the Office of General Counsel to ensure the Tomah VA Medical Center Policy PCS-SW-17 Emergency Detention is consistent with Wisconsin law.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director strengthens processes for staff to consider next of kin or family notification in the emergency detention of patients who may not comprehend their legal rights.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director ensures compliance with institutional disclosure procedures, as required by the Veterans Health Administration.
Date Issued
|
Report Number
21-01502-240
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/4/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement action items recommended by the committees responsible for quality, safety, and value oversight functions.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facilities peer review all applicable suicides.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that root cause analyses include a review of the underlying systems to determine where system redesigns might reduce risk.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement approved root cause analysis action items and outcome measures show sustained improvement.
Date Issued
|
Report Number
21-00371-222
|
Topics: Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures that community health nurses evaluate patients referred for homemaker and/or home health aide services in accordance with Veterans Health Administration policy when determining patient eligibility.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/25/2023
The Fayetteville VA Medical Center Director verifies that interdisciplinary assessments of homemaker and/or home health aide referrals are completed to determine patient eligibility for services.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The Fayetteville VA Medical Center Director ensures that community health staff are trained on the eligibility criteria for homemaker and/or home health aide services.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/10/2022
The Fayetteville VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of North Carolina commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures that providers consistently assess and document when patients lack decision-making capacity.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures thatproviders consistently determine whether a patient has an identified healthcare agent when patients lack decision-making capacity.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Fayetteville VA Medical Center Director makes certain that patient aligned care team providers and outpatient psychiatrists are educated about initiating specialty care consults for patients.
Date Issued
|
Report Number
21-00232-205
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator reports directly to the Director or one supervisory level below the Director.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and core members consistently attend meetings.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group reviews surgical deaths and National Surgery Office surgical quality reports, analyzes efficiency and utilization metrics, and recommends appropriate actions to the System Director.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that specific action items are implemented and monitored when problems or opportunities for improvement are identified.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory training prior to developing suicide safety plans.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
20-03635-217
|
Topics: COVID-19
● Mental Health
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA Medical Center policies.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while navigating the COVID-19 screening and testing process, including visitor policies.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.
Date Issued
|
Report Number
21-00255-200
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
Date Issued
|
Report Number
20-03763-207
|
Topics: Mental Health
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director ensures mental health staff consult with the Intimate Partner Violence Assistance Program and safety plan, as warranted to address Intimate Partner Violence.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Ralph H. Johnson VA Medical Center Director ensures Inpatient Mental Health Unit resident physicians complete timely clinical documentation in accordance with Ralph H. Johnson VA Medical Center Policy.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director makes certain staff consult with the Office of General Counsel to determine reporting requirements of Intimate Partner Violence, as appropriate.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The Under Secretary for Health establishes clear guidance related to Intimate Partner Violence training requirements.
Date Issued
|
Report Number
20-01259-196
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/21/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager or designee includes all required review elements in root cause analyses.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs evaluate practitioners based on service-specific criteria.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines the reasons for noncompliance and makes certain the Executive Council of Medical Staff reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
The System Director evaluates and determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Suicide Prevention Coordinator provides in-person Operation S.A.V.E. training at new employee orientation.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations within the required time frame.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures are reviewed at least every three years and updated when there is a change in process or manufacturer’s instructions for use.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director for Patient Care Services evaluates and determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures that all employees who reprocess reusable medical equipment receive monthly continuing education.
Date Issued
|
Report Number
21-00657-197
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/7/2022
The VA Salt Lake City Healthcare System Director conducts a clinical review of the care provided to the patient on Monday (day 7), by Idaho Falls Community-Based Outpatient Clinic staff, and takes action as warranted.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The VA Salt Lake City Healthcare System Director reviews the processes involved in conducting root cause analyses to ensure that final reports contain complete and accurate information.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The VA Salt Lake City Healthcare System Director determines if an institutional disclosure is warranted following the completion of the clinical review of this patient’s care and takes action as necessary.