All Reports

The Deputy Secretary ensures mitigation of the high-risk pharmacy-related patient safety issues identified during the May 2021 National Center for Patient Safety visit.

The Under Secretary for Health evaluates whether the new electronic health record reflects accurate patient medication information per Veterans Health Administration requirements and takes action as indicated.

The Deputy Secretary ensures the resolution of pharmacy-related usability issues identified in this report.

The Deputy Secretary ensures correction of inaccurate medication data transmitted to the Health Data Repository.

The Under Secretary for Health determines the need for and implements a comprehensive strategy to review patients affected by inaccurate medication data transmitted to the Health Data Repository to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of institutional disclosures.

The Under Secretary for Health ensures patients affected by inaccurate medication data transmitted to the Health Data Repository are notified of the risk of harm per Veterans Health Administration requirements.

The Under Secretary for Health ensures legacy site providers are aware of mitigations needed for patients previously treated at a new electronic health record site and monitors compliance.

The Under Secretary for Health ensures that pharmacist staffing levels are assessed and addressed prior to the implementation of the new electronic health record at additional VA sites

The Under Secretary for Health evaluates the underlying technical and functional issues resulting in workarounds and educational materials needed to perform pharmacy-related operations within the new electronic health record and takes action as indicated.

The Deputy Secretary establishes ongoing monitors to ensure that scheduling procedures in the new electronic health record are functioning in accordance with Veterans Health Administration requirements.

The Under Secretary for Health evaluates minimum scheduling effort requirements for mental health appointments and takes action to ensure the implementation of standardized policy and procedures in the best interest of patient care.

The VA Central Ohio Healthcare System Medical Center Director conducts a full review of the care of the patient provided by the nurse practitioner and psychologist 1, and the supervisory psychologist’s oversight, consults with Human Resources and General Counsel Offices, and takes actions as warranted.

The VA Central Ohio Healthcare System Medical Center Director ensures compliance with the Caring Communication Program including the initiation and cessation of caring communications as required.

The Under Secretary for Health considers establishing written guidance related to documentation, leaders’ review, follow-up actions, and tracking of Lessons Learned in root cause analyses.

The Veterans Integrated Service Network Director ensures that patient advocacy staff within Veterans Integrated Service Network 12 are educated on the need to consult with patient safety staff when complaints involve patient safety concerns.

The Edward Hines, Jr. VA Hospital Director ensures a review is completed of the missed opportunities referenced in this report related to refitting and reeducating patients on VA-issued shoes, determines the need to create a related standard operating procedure or facility policy, and takes action as necessary.

Ensure the DALC Recreation Group’s operations fully comply with VA Handbook 5025, Part VIII, or dissolve the group if there is insufficient employee interest in its continuation.

Update VA Handbook 7002, Logistics Management Procedures Part 3, section 7, to clarify under which circumstances, if any, VA employees are permitted to request, accept, and record any incentive items provided by vendors in connection with government purchases.

Reinforce ethics and policy requirements on the acceptance and disposition of free or donated property with all Denver Logistics Center managers and staff, including distributing to staff the Office of General Counsel’s guidance dated June 30, 2023.

Reeducate DLC managers, approving officials, and purchasing agents about VA government purchase card policy requirements that government contracted sources be fully considered and given priority when making purchases.

In consultation with the Office of General Counsel, as authorized by 31 U.S.C. § 3711, determine the full magnitude of the loss from the DALC Recreation Group’s improper sale of VA property and take appropriate action to recover the losses, including any proceeds of the auctions currently within the custody or control of the DALC Recreation Group.

Consider whether any administrative action should be taken with respect to the conduct or performance of the director of the Denver Logistics Center or any other individual involved in the improper acquisition and disposition of the incentive items, and report to the OIG any actions taken involving these individuals.

The Chief of Staff ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ Ongoing Professional Practice Evaluations.

The Chief of Staff ensures service chiefs regularly monitor licensed independent practitioners’ performance through Ongoing Professional Practice Evaluations.

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

The Under Secretary for Health examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA health care and those who did not in order to improve outreach efforts to the nearly half who did not engage with VA health care.

The Under Secretary for Benefits evaluates the service-connected disability application and claims process for veterans who reported sexual assault that occurred during military service to identify and mitigate potential barriers.

The Under Secretary for Benefits examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA benefits and those who did not in order to improve outreach efforts.

The VA Maine Healthcare System Director confirms that staff complete the Columbia-Suicide Severity Rating Scale and document on the Veterans Health Administration template when patients are unwilling to participate in completion of the screening.

The VA Maine Healthcare System Director oversees a review to determine whether a VA Maine Healthcare System policy in which clinical staff will be expected to develop safety plans with patients is needed; and if so, ensures one is created.

The VA Maine Healthcare System Director verifies that patients identified as having suicidal ideations or behaviors have personalized safety plans documented in the electronic health record, and monitors compliance.

The VA Maine Healthcare System Director assesses staff knowledge of when to notify the VA Maine Healthcare System suicide prevention staff about a patient who has made a threat of self-directed violence during a phone call with VA staff, and takes action as warranted.

The VA Maine Healthcare System Director ensures that VA Maine Healthcare System leaders and root cause analysis teams are trained in the process for responding to concerns with root cause analysis team findings according to VA National Center for Patient Safety guidance, and monitors adherence.

The VA Maine Healthcare System Director ensures that a review of the episode of care prior to the patient’s death is completed to determine whether peer reviews are warranted, and takes action accordingly.

The VA Maine Healthcare System Director confirms that VA Maine Healthcare System leaders, risk managers, and patient safety staff have knowledge of the types of quality management reviews that can and cannot be done concurrently.

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

The Chief of Staff ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.

The Director ensures the Patient Safety Manager documents start dates for sentinel event investigations in the Joint Patient Safety Reporting system.

The Director ensures the Patient Safety Manager initiates a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

The Director ensures executive leaders consolidate all credentialing and privileging activities into one credentialing and privileging office under the Chief of Staff.

The Director ensures the Credentialing and Privileging Manager reports directly to the Chief of Staff.

The Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

The Carl Vinson VA Medical Center Director ensures that the Sterile Processing Services chief conducts comprehensive staff competency assessments for the reprocessing of reusable medical equipment, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that the CensiTrac Instrument Tracking System is fully implemented, and that training is provided to the CensiTrac coordinator and Sterile Processing Services staff, and monitors for compliance.

The Carl Vinson VA Medical Center Director evaluates and ensures that Sterile Processing Services maintains a safe and clean environment in all areas where decontamination, sterilization, or clean and sterile storage of reusable medical equipment are performed, and monitors for compliance.

The Carl Vinson VA Medical Center Director develops an action plan for remediation of the location and use of the training room adjacent to Sterile Processing Services’ clean and sterile storage area, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that clinic areas, including radiology, have or share a designated soiled utility room as required by Veterans Health Administration policy, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that Sterile Processing Service standard operating procedures for reusable medical equipment are developed, updated consistent with manufacturer’s instructions for use, disseminated, and available at the point of use, and monitors for compliance.

The Veterans Integrated Service Network Director reviews the facility’s Sterile Processing Service water management program and takes action as necessary to ensure compliance with Veterans Health Administration guidance, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that the facility Water Working Group submits critical water system test results to the Veterans Integrated Service Network Sterile Processing Services Management Board, as required, and monitors for compliance.

The Veterans Integrated Service Network Director ensures all critical water system test results are reviewed by the Veterans Integrated Service Network Sterile Processing Services Management Board, corrective action is taken when appropriate, and all corrective actions are reported to the National Program Office for Sterile Processing, and monitors for compliance.

The Chief of Staff ensures the Medical Executive Council reviews results of professional practice evaluations.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer provides oversight of the medical center’s privileging process.

The Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.

The Medical Center Director ensures staff keep patient care areas clean and safe.

The Medical Center Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

The Director ensures staff complete individual root cause analyses for all adverse patient safety events with an actual or potential safety assessment code score of 3.

The Chief of Staff ensures service chiefs maintain sufficient data for licensed independent practitioners’ Ongoing Professional Practice Evaluations.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

The Medical Center Director ensures staff complete a minimum of eight patient safety analyses each year.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Focused and Ongoing Professional Practice Evaluations.

The Chief of Staff ensures service chiefs complete licensed independent practitioners’ Ongoing Professional Practice Evaluations on a regular basis.

The Medical Center Director ensures the suicide prevention coordinators report suicide-related events monthly to mental health leaders and quality management staff.

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

The Executive Director ensures Supply Chain Management, Engineering, or Facility Management Service staff monitor temperature and humidity in all clean and sterile storage rooms to maintain a stable environment.

The Executive Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.

The Executive Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen in ambulatory care settings.

The Associate Director ensures staff keep areas used by patients clean and orderly.

The Associate Director ensures staff store clean and dirty equipment and supplies separately.

The Associate Director ensures staff place all examination tables with the foot facing away from the door.

The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.