OIG evaluated allegations regarding oversight and perioperative patient safety. We did not substantiate lack of facility action after observing discolored surgical instruments or intraoperative microfibers, a surgeon’s responsibility for high or underreported blood loss, or facility failure to provide oversight of surgical events. Although we substantiated that a surgeon remained on duty following a sentinel event, we found no requirement for removal. We recommended conducting a risk assessment regarding temporary relief from duty. We did not substantiate delays in diagnosis or surgical mismanagement; however, we identified a lack of documentation and recommended that practitioners record treatment decision-making processes. We substantiated deficiencies in patient flow and recommended training for staff in perioperative locations on equipment and reporting near-miss patient safety incidents. We did not substantiate that the facility added surgery services without planning for support. While we substantiated canceled or delayed surgeries due to lack of beds, the facility acted to ensure bed availability. We substantiated allegations of poorly managed Rapid Response Team (RRT) and Cardiac Arrest Team (CAT) activity, although we did not confirm lack of oversight of patient deaths. We recommended strengthening and monitoring adherence to local policies regarding response to changing clinical conditions, complying with VHA standards for Emergency Department physicians, and designating one committee with responsibility for reviewing CAT and RRT processes.