VA officials were aware of problems, yet failed to improve patient safety at Puget Sound's hospitals, according to a report issued by the Joint Commission on the Accreditation of Health Care Organizations. In an unusual step, the commission recommended a "preliminary denial of accreditation." The report was made public by Washington's Sen. Patty Murray. Murray then called for an emergency meeting, and described a "lack of leadership." That was before she heard that information about a patient who harmed himself just hours before her visit had been kept from her.
