Text of Recommendation | The Lt. Col. Luke Weathers, Jr. VA Medical Center Director consider completion of another root cause analysis to ensure additional system vulnerabilities that may have contributed to this patient event are identified and action plans completed, as applicable, to prevent reoccurrence of similar patient events.
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Recommendation Number | 05 |
Recommendation Status | Open |
Significant Recommendation | No |
Submitting OIG | |
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Linked Report |