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Recommendation Details
Text of Recommendation
The Under Secretary for Health considers establishing written guidance related to documentation, leaders’ review, follow-up actions, and tracking of Lessons Learned in root cause analyses.
Recommendation Number
05
Recommendation Status
Open
Significant Recommendation
No
Recommendation Questioned Costs
$0
Recommendation Funds for Better Use
$0
Associated Report Details
Submitting OIG
Department of Veterans Affairs OIG
Linked Report
Scheduling Error of the New Electronic Health Record and Inadequate Mental Health Care at the VA Central Ohio Healthcare System in Columbus Contributed to a Patient Death