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

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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

Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.

Care systems for alcohol use disorder (AUD) patients are suboptimal. This report examines the case of a patient with AUD whose emergency care was mismanaged, uncoordinated, and incomplete, contributing to his death two days after discharge. The safety recommendations shared include improving discharge planning, assessment, and consideration of mental health conditions when caring for AUD patients.

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