Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

Book/Report

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

November 29, 2023

Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.

Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. This report examined factors contributing to poor disclosure practices associated with the care of three patients. Lack of report submission, uninitiated root cause analysis, and inadequate documentation were process weaknesses highlighted by the review.

Summary

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