Poor Paperwork Potentially Puts Patients at Risk: New Mexico VAMC Reuses Medical Devices without Documenting Proper Cleaning

Veteran Oversight Now

#Government #VA Office of Inspector General #VA OIG #Inspector General #Oversight #Veterans #Investigative

27:12

We are here at eTail Palm Springs and seeing and hearing the latest and greatest in e-commerce and retail. Question: Do you need to choose between AI and human recommendations as a customer? Why not have both? After all, don’t each have their strengths? AI in the retail experience is all the rage these days, but today I’m talking with someone from a brand that has been incorporating AI-personalized experiences and shopping combined with expert human recommendations for over 14 years, and continues to innovate today. Today we’re going to talk about how AI-based personalization plus human creativity and input makes an amazing customer experience at Stitch Fix. To help me discuss this topic, I’d like to welcome Noah Zamansky, Vice President of Product and Client Experience at Stitch Fix. About Noah Zamansky Noah Zamansky serves as the Vice President of Product and Client Experience at Stitch Fix, where he leads cross-functional teams spanning Product, Design, Engineering, Algorithms, and Platform Development. A seasoned leader, Noah has a proven track record of shaping product vision and strategy, designing exceptional user experiences, and spearheading the launch of new business ventures. Before joining Stitch Fix, Noah held the role of Senior Director of Product Management at eBay, overseeing Fashion and Vertical Experiences. Resources Stitch Fix: https://www.stitchfix.com eTail Palm Springs: https://etailwest.wbresearch.com/ Connect with Greg on LinkedIn: https://www.linkedin.com/in/gregkihlstrom Listen to The Agile Brand without the ads. Learn more here: https://bit.ly/3ymf7hd Don't miss a thing: get the latest episodes, sign up for our newsletter and more: https://www.theagilebrand.show Check out The Agile Brand Guide website with articles, insights, and Martechipedia, the wiki for marketing technology: https://www.agilebrandguide.com The Agile Brand podcast is brought to you by TEKsystems. Learn more here: https://www.teksystems.com/versionnextnow The Agile Brand is produced by Missing Link—a Latina-owned strategy-driven, creatively fueled production co-op. From ideation to creation, they craft human connections through intelligent, engaging and informative content. https://www.missinglink.company…

hace un año 22:36

MP3•Episodio en casa

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses findings at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico, where there was no documentation of required reusable medical device reprocessing, which put patients at risk for infection if the reusable medical devices used during subsequent procedures were, in fact, not cleaned per requirements. The VA OIG also found that high-level disinfection documentation was missing and made seven recommendations related to oversight of the medical center’s Sterile Processing Service. This episode also includes highlights of the VA OIG’s work from July 2024.

“If it’s [medical device] not documented properly and it’s not documented in the system so that we can track the cleaning, the disinfecting, the sterilization, then we don’t know if it’s processed appropriately.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

29 episodios

Poor Paperwork Potentially Puts Patients at Risk: New Mexico VAMC Reuses Medical Devices without Documenting Proper Cleaning

Veteran Oversight Now

published hace un año

MP3•Episodio en casa

29 episodios

#Government #VA Office of Inspector General #VA OIG #Inspector General #Oversight #Veterans #Investigative

All episodes

1
VON Podcast - IG Missal Highlights Latest Semiannual Report to Congress 15:41

hace un año15:41

15:41

In the latest episode of Veteran Oversight Now , VA Inspector General Michael J. Missal discusses the VA OIG’s latest Semiannual Report to Congress that covered oversight work from April 1 to September 30, 2024. This edition also includes highlights of the VA OIG’s work from October 2024. “I’m extremely proud of all the enhancements we’ve made and the exceptional improvements we helped to bring about for VA’s programs and operations, which ultimately improve the lives of veterans and their family members.” – VA Inspector General Michael J. Missal…

1
Unpaid Postage Bill Delays Critical Cancer Screenings—Rebroadcast 30:54

hace un año30:54

30:54

In this latest episode of Veteran Oversight Now , we’re revisiting a highly downloaded episode from February 2024— Unpaid Postage Bill Delays Critical Cancer Screenings . Hear from a VA OIG healthcare inspection hotline director, who discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from September 2024. “The VISN actually led a stand-down at the facility to retrain all of the laboratory staff about the test, about the assessing of the test and processing it. And then they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director…

1
Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center—Rebroadcast 26:36

hace un año26:36

26:36

In this latest episode of Veteran Oversight Now , we’re revisiting a highly downloaded episode from April 2024— Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center . Hear from a VA OIG healthcare inspection hotline director discuss how a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edition also includes highlights of the VA OIG’s work from August 2024. “Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue. Period.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee…

1
Poor Paperwork Potentially Puts Patients at Risk: New Mexico VAMC Reuses Medical Devices without Documenting Proper Cleaning 22:36

hace un año22:36

22:36

In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses findings at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico, where there was no documentation of required reusable medical device reprocessing, which put patients at risk for infection if the reusable medical devices used during subsequent procedures were, in fact, not cleaned per requirements. The VA OIG also found that high-level disinfection documentation was missing and made seven recommendations related to oversight of the medical center’s Sterile Processing Service. This episode also includes highlights of the VA OIG’s work from July 2024. “If it’s [medical device] not documented properly and it’s not documented in the system so that we can track the cleaning, the disinfecting, the sterilization, then we don’t know if it’s processed appropriately.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Deficiencies in Documentation of Reusable Medical Device Reprocessing and Failures in VISN 22 Oversight of Sterile Processing Service at the Raymond G. Murphy VAMC in Albuquerque, New Mexico…

1
Inadequate Care Coordination at the VA Southern Nevada Healthcare System in Las Vegas 31:06

hace un año31:06

31:06

In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses allegations that facility staff at the VA Southern Nevada Healthcare System in Las Vegas delayed ordering medications following an elderly patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide. “If you go by the timeline, this is 17 days after the patient’s first visit to the emergency room with the shortness of breath problems. . . . Unfortunately, the patient completed suicide that same day without receiving the medication.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director This podcast edition also includes highlights of the VA OIG’s work from June 2024. Related Report: Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas…

1
Patients Delayed Care Due to Failure to Follow Behavior Health Consult and Scheduling Process 23:15

hace un año23:15

23:15

In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses allegations that some patients’ behavioral health consults were being discontinued at the Oklahoma City VA Medical Center, which resulted in some significant delays in patients receiving recommended behavioral health services. This podcast edition also includes highlights of the VA OIG’s work from May 2024. “Both in the allegation and what we found was basically that the program manager lacked a working knowledge of the consult management and scheduling processes.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma…

1
IG Missal Highlights 91st Semiannual Report to Congress 22:45

hace un año22:45

22:45

In the latest episode of Veteran Oversight Now , VA Inspector General Michael J. Missal discusses the VA OIG’s latest Semiannual Report to Congress that covered our oversight work from October 1, 2023, to March 31, 2024. Specifically, he shares results of our most recent work related to VA’s Electronic Health Record Modernization program. To date, the VA OIG has published 19 products addressing the program’s implementation across VA facilities nationwide. In addition, IG Missal shares his thoughts on the VA OIG’s work related to VA’s personnel suitability program as well as recent crime and fraud alerts. A recent fraud alert encourages VBA staff to report when veterans share that they are being charged high fees from unaccredited individuals for assistance with completing disability benefits questionnaires (DBQs) or an initial claim filing. This podcast edition also includes highlights of the VA OIG’s work from April 2024. “It's wonderful to be able to talk about all the incredible work that our staff performs in the service of our nation's veterans. I could not be more proud of the progress our staff has made in achieving our mission to serve veterans and the public by conducting meaningful, fair, and evidence-driven oversight of VA.” – Inspector General Michael J. Missal. Related Report: 91s t Semiannual Report to Congress…

1
Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center 27:16

hace un año27:16

27:16

In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edition also includes highlights of the VA OIG’s work from March 2024. “Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue. Period.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee…

1
Chronic Leadership Failures Plague Cardiology Department at Indiana VAMC 26:02

hace un año26:02

26:02

In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses how multiple OIG reports detail chronic leadership failures at the Indianapolis, Indiana VA medical center. This edition also includes highlights of the VA OIG’s work from February 2024. “It overall affects the care that the patients receive. Some of the care just wasn’t available anymore because they didn’t have the cardiologists available.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director…

1
Unpaid Postage Bill Delays Critical Cancer Screenings 30:43

hace un año30:43

30:43

In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from January 2024. “The VISN actually led a stand-down at the facility to retrain all of the laboratory staff about the test, about the assessing of the test and processing it. And then they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona…

1
IG Missal Reflects on Inspector General 45th Anniversary and Latest Semiannual Report to Congress 36:21

hace un año36:21

36:21

In the latest episode of Veteran Oversight Now , VA Inspector General Michael J. Missal shares his thoughts on changes to federal oversight since the passage of the Inspector General Act in 1978, which established 12 presidentially appointed IGs in federal departments with a mission to provide independent oversight. The VA OIG was one of the original 12. He also discusses the VA OIG’s latest Semiannual Report to Congress that covered oversight work from April 1 to September 30, 2023. This edition also includes highlights of the VA OIG’s work from October 2023. “As only the sixth Senate-confirmed VA Inspector General over the past 45 years, it is truly an honor and privilege to work on behalf of veterans and taxpayers. It is also a real honor and privilege to work with all of our staff to meet our mission of meaningful independent oversight. We had a great fiscal year 2023 and we look forward to an even more impactful fiscal year 2024.” – VA Inspector General Michael J. Missal Related Reports: VA’s Compliance with the VA Transparency & Trust Act of 2021 Semiannual Report: September 2023 Manufacturers Failed to Make Some Drugs Available to Government Agencies at a Discount as Required Review of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19 Pandemic Read the VA OIG's 90th Semiannual Report to Congress .…

1
Lessons Learned after Patient Death following a Fall in a Las Vegas VA Outpatient Clinic 31:39

hace un año31:39

31:39

In this latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses the lessons learned in the care of a veteran who died after a fall in a VA outpatient clinic, part of the Southern Nevada Healthcare System in Las Vegas. This edition also includes highlights of the VA OIG’s work from August 2023. “Since [the incident] happened, the facility has made several adjustments to ensure that in an emergency situation that staff is knowledgeable of the processes that they need to implement and carry out that will hopefully result in a better outcome.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas Published: 6/28/2023 Report #22-02725-132…

1
“I don’t want to die.” Veteran Left Alone in VA Emergency Department Dies from Suicide 48:30

hace 2 años48:30

48:30

In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the VA St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023. “Approximately 10 minutes later is when the staff person finds the patient unresponsive in the exam room with a ligature around his neck. A code was called, meaning a code blue so that all emergency staff would present to that room, and they tried to resuscitate the patient, but that was unsuccessful, and he was pronounced dead about 10 to 15 minutes later.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri…

1
Veteran Suicide at Outpatient Clinic in South Carolina Highlights Tragic Missteps in Patient Care 47:21

hace 2 años47:21

47:21

In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA OIG’s work from June 2023. “In VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia…

1
Oversight, Employee Participation Critical to Patient Safety Programs Says Healthcare Hotline Director 38:50

hace 2 años38:50