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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However, internal data obtained last year by the Washington Free Beacon through the Freedom of Information Act (FOIA), revealed that VA hospitals across the country reported 575 “institutional disclosures of adverse events” in fiscal year 2013 in which patients were gravely injured or died as a result of the care they received. Based on the FOIA data, the article concluded that VA’s adverse events were system-wide.

Nonetheless, as GAO reports, VA medical centers (VAMCs) completed 18 percent fewer root cause analyses in fiscal year 2014 compared to fiscal year 2010—meant to recommend changes to prevent the recurrence of adverse events—and the VHA has not stated the reasons for the decrease.  

VHA’s National Center for Patient Safety (NCPS) oversees the root cause analysis process by monitoring VAMC compliance, yet NCPS officials told auditors they were aware of the decrease but were not certain why the number of completed RCAs had decreased over time, especially in light of a 7 percent increase in reported adverse events over the same time period.

“VHA’s lack of analysis is inconsistent with federal internal control standards which state that agencies should compare data to analyze relationships and take appropriate actions,” states GAO. “Because NCPS has not conducted an analysis of the relationship between the decrease in root cause analyses and possible contributing factors, it is unclear whether the decrease indicates a negative trend in patient safety at VAMCs or a positive one. In addition, without understanding the extent to which VAMCs use alternative processes and their results, NCPS has limited awareness of what VAMCs are doing to address the root causes of adverse events.”

GAO recommended that VA analyze the declining number of completed RCAs—including identifying the contributing factors and taking appropriate actions—and determine the extent to which VAMCs are using alternative processes to address adverse events, and collect information on their results. VA concurred with GAO’s recommendations.

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