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Medical Errors at VA Facilities Are Rising As Investigations Decline

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.

The 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.