Department of Veterans Affairs

The Office of Inspector General (OIG) conducted an inspection to assess a safety concern with the new electronic health record (EHR) that resulted in patient harm. The OIG found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of to...

Pursuant to the VA Choice and Quality Employment Act of 2017 (VCQEA), the OIG conducted a review to identify clinical and non-clinical occupations experiencing staffing shortages within Veterans Health Administration (VHA). This is the ninth iteration of the staffing report, and the fifth evaluating...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 5: VA Capitol Health Care Network in Linthicum, Maryland, covering leadership and...

This administrative investigation addressed concerns of possible misconduct by two leaders responsible for overseeing medical facility staff training on implementing VA’s new multibillion-dollar patient electronic health record system. The investigation stemmed from a prior OIG review at the initial...

In the course of its work, the OIG learned that survey records for VA educational programs submitted remotely during the pandemic lacked sufficient protection for students’ personally identifiable information. This management advisory memorandum conveyed information needed for the Veterans Benefits...

The VA Office of Inspector General (OIG) assessed the VA Boston Healthcare System’s stewardship and oversight of funds in fiscal year (FY) 2021 and identified potential cost efficiencies in carrying out medical center functions. The review team looked at open obligation oversight, purchase card use...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Maryland Health Care System, which includes the Baltimore, Loch Raven, and Perry Point VA...

The VA Office of Inspector General (OIG) conducted this review to determine whether VA complied with the requirements of the Payment Integrity Information Act of 2019 (PIIA) for fiscal year (FY) 2021. The PIIA, enacted in March 2020, requires federal agencies to identify and review all programs and...

Refrigerated pharmaceuticals must be stored within manufacturer-recommended temperature ranges to maintain their potency. Exposure to excessive heat, cold, or light can cause these pharmaceuticals to lose potency, risking significant waste of medical and financial resources.In January 2019, VA...

The VA Office of Inspector General (OIG) assessed allegations at the New Mexico VA Health Care System (facility) regarding the policy and practices related to the provision of buprenorphine treatment for patients with opioid use disorder.The OIG substantiated that pharmacists declined early refills...