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

Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No. 19-00468-67.

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January 29, 2020
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No. 19-00468-67.

Systemic weaknesses challenge safe care in Veterans Affairs health systems facilities. This report analyzed a patient suicide at one medical center and determined contributors to the failure. This report shares recommendations to address deficiencies including improved communication across the care continuum and reliably acting on root cause analysis results.