Healthcare Facility Inspection of the Durham VA Health Care System in North Carolina

The OIG recommends that executive leaders ensure staff store all high-alert medications in a secure or locked area.

The OIG recommends that executive leaders ensure staff follow their processes to prevent the storage of expired medical supplies and that supply areas remain clean.

The OIG recommends that executive leaders ensure staff keep the facility free of temporary signage that may interfere with cleaning and disinfection processes.

The OIG recommends that the patient safety manager confirms staff enter known patient safety events into the Joint Patient Safety Reporting system for use in the initial assessment of these events.

The OIG recommends that executive leaders ensure quality management staff implement an oversight process to validate providers’ compliance with patient communication and follow-up for urgent, noncritical abnormal test results.

The OIG recommends executive leaders evaluate options to improve safety at the informal crossing area near parking garage B.

The OIG recommends that executive leaders ensure all directories are accurate and provide specific details so veterans can easily navigate the facility.

The OIG recommends that executive leaders implement additional features to aid veterans with sensory impairments to navigate the facility.

The OIG recommends that executive leaders ensure staff train patient escorts on how to effectively communicate with sensory-impaired veterans.

The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.

The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.