At a time when adverse events are increasing at the Department of Veterans Affairs, the VA has decreased the number of root cause analyses designed to identify and evaluate its systems or processes that might be causing injury or death to patients, according to the Government Accountability office in a new audit.

The VA’s Veterans Health Administration (VHA) operates one of the nation’s largest integrated healthcare delivery systems, with more than 1,700 hospitals, clinics, and other facilities. Consequently, the potential risk for adverse events is substantial.

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