VA Examinations of Medical Errors Decreased 18 Percent Since 2010

Medical centers completed fewer ‘root-cause’ analyses even as adverse events increased by 7 percent

Veterans Affairs hospital in Pittsburgh / AP

A new audit shows that the Department of Veterans Affairs has decreased its efforts to determine the cause of medical mistakes over the course of a four-year period despite a host of scandals, failures, and deaths plaguing the department-run medical centers in recent years.

The Government Accountability Office, tasked with reviewing the VA’s processes and procedures for responding to adverse events that occur within its health care system, found that the VA failed to make use of an oversight procedure known as a root-cause analysis. The agency performed these analyses 18 percent less in fiscal year 2014 than in 2010.

Adverse events 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," according to the GAO. A root cause analysis process at VA medical centers initially begins when a patient safety manager learns of an adverse event and determines a "safety assessment score" in relation to the problem. A medical center director then puts together a multidisciplinary team that identifies and documents root causes, actions, and outcome measures.

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The team presents the RCA report to leadership and a patient safety manager, then submits the final RCA report to the National Center for Patient Safety. The process, up to this point, takes 45 days to complete. The patient safety manager is tasked with following up on the implementation of actions recommended in the analysis.

The audit found that 1,862 such analyses were performed in 2010. This number dipped to 1,743 in 2011 and decreased yet again to 1,664 in 2012. In 2014, the number fell once more to 1,523, an 18 percent decrease from 2010.

During the same time frame the decrease in examinations of medical problems occurred, the amount of adverse events within the system was found to increase by 7 percent.

The investigation states that it is "unclear whether the 18 percent decrease in total RCAs completed from fiscal year 2010 to fiscal year 2014 is a negative trend reflecting less reporting of serious adverse events, or a positive trend reflecting fewer serious adverse events that would require an RCA."

The accountability office also says that in recent years staff have felt less open about making adverse events known.

"Officials stated that they have observed a change in the culture of safety in recent years in which staff feel less comfortable reporting adverse events than they did previously," the report found.

The accountability office recommended an investigation into the decline in root-cause analyses. It also advised medical centers to determine the extent to which they used alternative processes to address the root causes of adverse events when a regular analysis may not be required.