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

Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.

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November 13, 2013
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.

This investigation into three patients who died in an emergency department uncovered problems related to medication ordering, alert response, and test result tracking.