Even though medical errors are on the rise, healthcare facilities run by
the Department of Veterans Affairs (VA) are conducting fewer investigations
into their causes, according to the United States Government Accountability
Office (GAO). The GAO’s findings are alarming in light of recent
reports regarding the quality of patient care and unacceptable wait times
for necessary procedures.
GAO report specifically looked at “adverse events,” which are defined
as incidents that pose a risk of injury to a patient as the result of
a medical intervention or the lack of an appropriate intervention. When
mistakes occur, Department of Veterans Affairs medical centers (VAMC)
are supposed to use a specific process, called root cause analyses (RCA),
to identify and evaluate systems or processes that caused an adverse event,
recommend changes to prevent the event’s recurrence, and determine
whether implemented changes were effective.
The analysis revealed VAMCs completed 18 percent fewer root cause analyses
in fiscal year 2014 compared to fiscal year 2010. During the same period,
there was a seven percent increase in reports of adverse events.
According to the report, VA officials acknowledged that they were aware
of the decrease, but were not certain why the number of completed investigations
had decreased over time. Because the VA failed to analyze the relationship
between the decrease in RCAs and possible contributing factors, the GAO
report notes that it is unclear whether the decrease indicates a negative
trend in patient safety at VAMCs or a positive one.
Going forward, the GAO recommends that the VA determine whether fewer serious
adverse reports are being reported or hospitals are using alternative
processes to investigate them. “The lack of complete information
may result in missed opportunities to identify needed system-wide patient
safety improvements,” the report states.
If you or someone you love has suffered from medical error at a VA facility,
don’t hesitate to contact
a San Diego medical negligence lawyer at the Law Offices of Robert Vaage
for a free consultation.