VA Health Care: VA Medical Centers Need to Improve Monitoring of
High-Risk Patients (Letter Report, 12/10/93, GAO/HRD-94-27).

After two patients were found dead on the grounds of a Department of
Veterans Affairs (VA) medical center, GAO investigated and found that
"high risk" patients--those unable to care for themselves--who wander
away are a significant problem at 39 of 158 VA medical centers.  In a
recent 2-year period, more than 100 searches were conducted for
high-risk patients at 20 VA medical centers. Patients leave their
treatment settings without staff knowledge primarily when medical center
staff (1) underestimate the potential for these patients to wander off
without authorization or (2) fail to closely watch all high-risk
patients while they are in the facility or on its grounds.  During the
same 2-year period, about 7,000 searches were conducted throughout the
VA system for high-risk patients who were reported missing.  About 99
percent of these patients were ultimately found unharmed; 34 were found
dead and 19 injured.  VA is working to develop search procedures for
these high-risk patients who disappear without staff knowledge and
approval.  The goal is to find these persons before they leave the
medical center grounds.  But VA also needs to do a better job of
monitoring high-risk patients to prevent unauthorized departures in the
first place.  Further, VA can do more to locate unaccounted-for
patients.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HRD-94-27
     TITLE:  VA Health Care: VA Medical Centers Need to Improve 
             Monitoring of High-Risk Patients
      DATE:  12/10/93
   SUBJECT:  Veterans hospitals
             Mental care facilities
             Patient care services
             Mental health care services
             Physicians
             Medical records
             Hospital administration
             Health care personnel
             Monitoring
             Information dissemination operations

             
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