The Office of Inspector General said that some veterans’ medical centers must communicate more about transfers between VA facilities. Some missteps could have affected patient safety, the OIG said.
Veterans’ hospitals must do a better job of monitoring patient transfers and ensuring patients are getting the appropriate medications when they go to other facilities, according to a new report.
The Office of Inspector General of the Department of Veterans Affairs issued the report Thursday. The inspector general’s office conducted 45 unannounced inspections at 45 VA medical facilities from Nov. 30, 2020 through Aug. 23, 2021. The review looked at how the hospitals and medical centers handled transfers of patients to other VA facilities.
The missteps, particularly in communicating about medications, could have affected patient safety, the report said.
The findings “may help leaders identify vulnerable areas or conditions that, if properly addressed, could improve patient safety and healthcare quality,” the report stated.
The inspector general’s office issued four key recommendations for the VA.
Provide medication lists: Some facilities need to do a better job of ensuring that they are sending patient medication lists and other pertinent information when they are transferring patients. The inspector general’s office said it didn’t find evidence of transferring medication lists for an estimated 30% of inter-facility transfers, above the benchmark of 10%, the report said. The report also said there was no evidence of staff providing a copy of advance directives in 72% of the facilities. “These deficiencies could have resulted in suboptimal treatment decisions that may have compromised patient safety,” the report said.
Develop policies: The VA needs to ensure its facilities have a policy for transfers on the books. While the VA requires facilities to have such policies, the inspector general’s review found that 18% of the facilities that were inspected didn’t have an inter-facility transfer policy. The lack of a policy “could result in lack of coordination between facilities to provide seamless care for patients,” the inspector general’s report said.
Better monitoring: VA facilities must do a better job of monitoring the transfers of patients to other VA facilities. The inspector general said it couldn’t find evidence of staff monitoring and evaluating transfers at 45% of the facilities reviewed. By not monitoring the transfers, facilities are missing opportunities to improve, the report said.
Nurse communication: The VA requires facilities to ensure nurses are communicating when patients are transferred from one VA medical center to another. There was no evidence of nurse-to-nurse communication in 20% of the inter-facility transfers, according to the inspector general’s office. “This could have resulted in staff at the receiving facility lacking the information needed to care for patients,” the report said.
The VA generally agreed with the inspector general’s findings, the report said. The inspector general’s office said it will follow up to gauge progress.