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Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.
Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. Washington DC: Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140.
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May 26, 2021
Washington DC: Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140.
Health care system failures can enable unrecognized, persistent criminal behavior. This report examines conditions contributing to a serial murder case including weaknesses in mortality data analysis, clinical documentation review, patient safety incident reporting, medication security processes, and safety culture.
