Date Issued
|
Report Number
06-03056-221
All Reports
Date Issued
|
Report Number
15-00074-207
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Intensive Care Unit Committee document the review of each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Chief of Staff attend Surgical Work Group meetings and that the Surgical Work Group document its review of National Surgical Office reports.
No. 4
to Veterans Health Administration (VHA)
We recommended that the Facility Director approve and sign written requests for extensions for final peer reviews.
No. 5
to Veterans Health Administration (VHA)
We recommended that Environment of Care Committee meeting minutes consistently include discussion regarding community based outpatient clinic rounds deficiencies.
No. 6
to Veterans Health Administration (VHA)
We recommended that the Infection Control Committee meeting minutes consistently include implementation of actions to address all high-risk areas, follow-up on implemented actions, and analysis of surveillance activities and data.
No. 7
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas are in good repair and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
We recommended that the facility correctly tag critical medical equipment on the intensive care unit and inspect and maintain it as recommended by the manufacturer and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
We recommended that the facility remove inoperable medical equipment from use.
No. 10
to Veterans Health Administration (VHA)
We recommended that the facility annually review the look-alike and sound-alike medication list.
No. 11
to Veterans Health Administration (VHA)
We recommended that the facility conduct a contrast reaction emergency drill in magnetic resonance imaging and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
We recommended that Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
We recommended that facility managers post stroke guidelines on all required units.
No. 15
to Veterans Health Administration (VHA)
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
No. 19
to Veterans Health Administration (VHA)
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 20
to Veterans Health Administration (VHA)
We recommended that the facility develop and grant a scope of practice that includes emergency airway management for respiratory therapists who have established competency to perform the procedure.
Date Issued
|
Report Number
14-00378-208
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinical managers complete improvement actions related to peer review and report the completion to the Peer Review Committee and that the Peer Review Committee submits quarterly reports to the Medical Executive Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that the Medical Executive Committee documents approval when telemedicine services are received or provided.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinical managers reassess observation criteria and/or utilization when the conversion rate from observation to admission was greater than the allowed percent.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinicians complete reviews of inpatients’ continuing stays.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirement for an interdisciplinary committee to review individual resuscitation episodes and for facilities to collect resuscitation data.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for Surgical Work Groups to meet monthly, include the Chief of Staff as a member, monitor surgical performance improvement activities, and review National Surgery Office reports.
Date Issued
|
Report Number
09-00313-273
Date Issued
|
Report Number
08-01865-244
Date Issued
|
Report Number
07-00645-243
Date Issued
|
Report Number
08-01704-246
Date Issued
|
Report Number
11-01978-247
Date Issued
|
Report Number
05-03285-225
Date Issued
|
Report Number
06-01512-224
Date Issued
|
Report Number
10-00126-230
Date Issued
|
Report Number
10-00689-231
Date Issued
|
Report Number
11-00446-234
Date Issued
|
Report Number
09-03665-232
Date Issued
|
Report Number
10-02487-235
Date Issued
|
Report Number
10-03888-240
Date Issued
|
Report Number
11-00374-239
Date Issued
|
Report Number
11-00057-238
Date Issued
|
Report Number
11-01082-237
Date Issued
|
Report Number
11-01499-236