Report Summary

Title: Combined Assessment Program Summary Report – Evaluation of Moderate Sedation in Veterans Health Administration Facilities
Report Number: 13-01743-192
Issue Date: 5/2/2013
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted
Summary: OIG completed an evaluation of moderate sedation in Veterans Health Administration (VHA) facilities. The purpose of the evaluation was to determine whether VHA facilities used safe processes for the provision of moderate sedation that complied with selected requirements. OIG conducted this review at 44 facilities during Combined Assessment Program reviews performed from October 1, 2011, through September 30, 2012, and identified three areas where VHA facilities needed to improve compliance. OIG recommended that clinicians consistently document all required elements of comprehensive pre-procedure assessments; that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change; and that clinicians consistently discharge moderate sedation patients appropriately and safely.