Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.

Book/Report

Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.

February 24, 2016

Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.

The Veterans Health Administration faces various challenges to providing safe care, including poor continuity during transitions to different locations which can result in inappropriate discontinuation of medications that patients require. This government report discuses efforts to reduce gaps in medication access and suggests developing clear policies to prevent patient harm in this population.

Information

Summary (PDF)

Free full text (PDF)

Related Resources From the Same Author(s)

Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.

March 9, 2016

Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care.

May 4, 2016

Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.

July 20, 2016

Approaches and Challenges to Electronically Matching Patients' Records Across Providers.

March 6, 2019

Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.

March 13, 2019

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

September 5, 2012

VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.

November 9, 2011

Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.

July 11, 2018

Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.

May 16, 2018

Actions Needed to Address Employee Misconduct Process and Ensure Accountability.

August 15, 2018

Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm.

November 22, 2017

Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.

December 6, 2017

Patient Options for Safe and Effective Disposal of Unused Opioids.

September 25, 2019

Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.

October 15, 2008

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events.

September 9, 2015

DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers.

November 28, 2012

Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.

March 19, 2014

Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.

February 19, 2014

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

January 19, 2022

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

May 27, 2020

Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.

August 15, 2012

Patient Safety Act.

February 10, 2010

VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.

January 15, 2014

Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.

April 29, 2020

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.

April 30, 2008

Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care.

December 9, 2020

VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.

July 5, 2006

VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities.

January 4, 2006

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

October 26, 2022

Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.

January 31, 2006

Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened.

July 12, 2006

VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.

July 5, 2006

Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns.

December 23, 2020

Final Report of the Commission on Care.

August 3, 2016

Patient Safety 2015: Final Technical Report.

November 12, 2014

Identification and Prioritization of Health IT Patient Safety Measures.

March 16, 2016

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

National Action Plan for Adverse Drug Event Prevention.

September 24, 2014

National Action Plan to Improve Health Literacy.

June 16, 2010

Antibiotic Stewardship in Acute Care: A Practical Playbook.

July 13, 2016

When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"?

April 27, 2016

Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care.

October 5, 2016

A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.

July 27, 2016

Adverse Events in Hospitals: Public Disclosure of Information About Events.

January 20, 2010

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.

February 9, 2011

Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.

June 29, 2016

Oversight Hearing on Recent Patient Safety Issues.

June 28, 2006

Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota.

January 29, 2020

Safety Assurance Factors for EHR Resilience: SAFER Guides.

January 29, 2014

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Preventable Tragedies: Superbugs and How Ineffective Monitoring of Medical Device Safety Fails Patients.

February 3, 2016

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

January 18, 2012

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.

February 11, 2015

PHSO Review: Quality of NHS Complaints Investigations.

June 22, 2016

Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.

December 12, 2018

Health IT Patient Safety Action and Surveillance Plan.

July 17, 2013

A Conversation on Transparency and Patient Safety.

April 13, 2016

Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021.

October 18, 2023

Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.

November 30, 2016

Health IT Safety Center Roadmap.

July 29, 2015

Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care.

July 19, 2017

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Medicare's Oversight of Ambulatory Surgery Centers Report.

October 23, 2019

Health-Care–Associated Infections in Hospitals: Continuing Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections.

April 15, 2009

Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee.

January 31, 2024

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

June 13, 2012

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

June 4, 2014

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Medication Management: Detailed Use Case.

July 4, 2007

Evidence Brief: Implementation of High Reliability Organization Principles.

July 24, 2019

Toward a High Performance Health System: Public-Private Efforts to Make Health Care Safer and More Effective.

October 19, 2005

Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention.

September 18, 2013

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

September 30, 2020

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

Clinician Well-Being Knowledge Hub.

April 4, 2018

NAM Action Collaborative on Clinician Well-Being and Resilience.

February 15, 2017

Patient Safety Measures.

December 11, 2013

Drug Shortages: FDA's Ability to Respond Should Be Strengthened.

January 4, 2012

Critical Deficiencies at the Washington DC VA Medical Center.

March 21, 2018

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee.

November 13, 2013

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

July 14, 2021

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Safe Practices for Better Healthcare: 2010 Update.

April 21, 2010

Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

August 10, 2022

Related Resources

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

April 3, 2024

Annual Perspective

Equity in Patient Safety

March 27, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

October 25, 2023

A Transformational Effort on Patient Safety.

September 13, 2023

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action.

June 28, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

February 1, 2023

Diagnostic Errors in the Emergency Department: A Systematic Review.

December 21, 2022

Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety.

December 21, 2022

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

December 14, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network.

August 17, 2022

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors: Guidance for Industry.

May 25, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

An Investigation into the Death of Baby J at University Hospitals Bristol and Weston NHS Foundation Trust.

November 3, 2021

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

The Safety of Maternity Services in England.

August 25, 2021

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

July 14, 2021

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

May 26, 2021

Coronavirus Commission for Safety and Quality in Nursing Homes.

March 10, 2021

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Best Practices in Developing Proprietary Names for Human Nonprescription Drug Products.

January 13, 2021

Best Practices in Developing Proprietary Names for Human Prescription Drug Products Guidance for Industry.

December 23, 2020

See More About The Topic

Specialty Hospitals

Health Care Providers

Medicine

Discontinuities, Gaps, and Hand-Off Problems

Epidemiology of Errors and Adverse Events

Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site