GAO: VA Medical Errors Increased While Investigations Declined
While the number of reported adverse medical events at Department of Veterans Affairs facilities increased by 7% between fiscal year 2010 and FY 2014, the number of root-cause investigations into such events decreased by 18%, according to a new report from the Government Accountability Office, the Washington Post's "Federal Eye" reports.
GAO said it was difficult to determine whether the drop in investigations means fewer errors were reported or that the number of errors is increasing but they are not serious enough to merit attention. The report did not examine why there was a drop in investigations.
For the report, GAO examined data on adverse events from the entire VA system of 150 hospitals and clinics, with deeper investigations into four facilities. It conducted the report at the request of:
- Sen. Richard Blumenthal (D-Conn.);
- Sen. Bernie Sanders (I-Vt.);
- Sen. Patty Murray (D-Wash.);
- Rep. Corrine Brown (D-Fla.); and
- Rep. Eddie Bernice Johnson (D-Texas).
Adverse events are incidents that harm a patient and are not a direct result of the patient's underlying medical condition. Adverse events can also occur when needed interventions are not performed. Such errors are considered to be preventable, according to "Federal Eye."
Root cause analyses are conducted on such events based on their severity. High-risk events that are likely to be repeated must be investigated, while hospital staff can decide whether to investigate lower-risk events.
According to GAO, VA officials are not sure why VA is completing fewer investigations into adverse events. The report noted that the National Center for Patient Safety, which monitors medical error investigations for the Veterans Health Administration, "has limited awareness of what hospitals are doing to address the root causes of adverse events." The report added, "[T]he lack of complete information may result in missed opportunities to identify needed system-wide patient safety improvements."
In addition, GAO noted that VA patient safety officials said they had noticed a "change in the culture of safety" at many VA hospitals, as "staff feel less comfortable reporting adverse events than they did previously." According to the report, officials pointed to a "periodic survey on staff perceptions of safety," which "showed decreases from 2011 on questions measuring staff's overall perception of patient safety, as well as decreases in perceptions of the extent to which staff work in an environment with a nonpunitive response to error."
VA generally agreed with the report's conclusions, according to "Federal Eye." VA officials noted that while some hospitals might use other methods to review medical errors, such methods "are not a replacement" for root-cause analyses.
A review of the issue by VA's patient safety office is underway and scheduled to be completed in November (Rein, "Federal Eye," Washington Post, 8/31).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.