VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events (open access)

VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events

A letter report issued by the Government Accountability Office with an abstract that begins "The Department of Veterans Affairs (VA) medical centers GAO visited did not adhere to certain policy elements of the protected peer review process, and monitoring by VA's Veterans Health Administration (VHA) is limited. According to policy issued by VHA, protected peer review may be used by VA medical centers (VAMC) when there is a need to determine whether a provider's actions associated with an adverse event were clinically appropriate--that is, whether another provider with similar expertise would have taken similar action. Despite VAMC officials' general understanding of the protected peer review process, none of the VAMCs GAO visited adhered to all four protected peer review policy elements selected for review, including the timely completion of reviews, and the timely development of peer review triggers that signal the need for further review of a provider's care. Failure of VAMCs to adhere to the protected peer review policy elements may result in missed opportunities to identify providers who pose a risk to patient safety. Veterans Integrated Service Networks (VISN), responsible for oversight of VAMCs, monitor VAMCs' protected peer review processes through quarterly data submissions and annual site visits. …
Date: December 3, 2013
Creator: United States. Government Accountability Office.
Object Type: Report
System: The UNT Digital Library
Oral History Interview with Richard Overton, December 3, 2013 (open access)

Oral History Interview with Richard Overton, December 3, 2013

The National Museum of the Pacific War presents an interview with Richard Overton. Overton joined the Army in 1942. He served with the 1887th Engineer Aviation Battalion, an all-black unit that served on various islands in the Pacific. They participated in the Palau Campaign and the Battle of Okinawa. Their battalion assisted in building an airfield. He returned to the US and was discharged in 1945. He gained fame as the oldest living WWII veteran until his death in 2018.
Date: December 3, 2013
Creator: Overton, Richard
Object Type: Text
System: The Portal to Texas History
The Altus Times (Altus, Okla.), Vol. 114, No. 182, Ed. 1 Tuesday, December 3, 2013 (open access)

The Altus Times (Altus, Okla.), Vol. 114, No. 182, Ed. 1 Tuesday, December 3, 2013

Daily newspaper from Altus, Oklahoma that includes local, state, and national news along with advertising.
Date: December 3, 2013
Creator: Bush, Michael
Object Type: Newspaper
System: The Gateway to Oklahoma History
Rains County Leader (Emory, Tex.), Vol. 127, No. 26, Ed. 1 Tuesday, December 3, 2013 (open access)

Rains County Leader (Emory, Tex.), Vol. 127, No. 26, Ed. 1 Tuesday, December 3, 2013

Weekly newspaper from Emory, Texas that includes local, state, and national news along with advertising.
Date: December 3, 2013
Creator: Hill, Trey
Object Type: Newspaper
System: The Portal to Texas History
Oral History Interview with Richard Overton, December 3, 2013 transcript

Oral History Interview with Richard Overton, December 3, 2013

The National Museum of the Pacific War presents an interview with Richard Overton. Overton joined the Army in 1942. He served with the 1887th Engineer Aviation Battalion, an all-black unit that served on various islands in the Pacific. They participated in the Palau Campaign and the Battle of Okinawa. Their battalion assisted in building an airfield. He returned to the US and was discharged in 1945. He gained fame as the oldest living WWII veteran until his death in 2018.
Date: December 3, 2013
Creator: Overton, Richard
Object Type: Sound
System: The Portal to Texas History