The purpose of the review was to evaluate the care provided to patients treated at Veterans Health Administration facilities who developed potentially preventable pulmonary embolism. This evaluation was also a follow-up to the OIG’s report Healthcare Inspection – Prevention of Venous Thromboembolism in VA Hospitals (Report No. 06-02459-209, September 26, 2008). OIG conducted this review at 29 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2012, through March 31, 2013, and encouraged facility management to expand peer review and to monitor the rate of preventable pulmonary embolism at their facilities. While OIG made several recommendations during facility Combined Assessment Program reviews, OIG made no recommendations in this report.