- The Government Accountability Office released a report stating VA’s medical centers completed 18% fewer analyses in FY 2014, compared with FY 2010.
- In the same period, reports of adverse events increased 7%.
- Veterans Health Administration’s National Center for Patient Safety (NCPS) told GAO “they were aware of the decrease, but were not certain why the number of completed [root cause analyses] had decreased over time.”
According to the report, NCPS officials suggested that VAMC’s use of processes other than root cause analyses to address adverse events could have contributed to the investigation decrease.
“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,” the executive summary states. “Because NCPS has not conducted an analysis of the relationship between the decrease in RCAs and possible contributing factors, it is unclear whether the decrease indicates a negative trend in patient safety at VAMCs or a positive one.”
The government watchdog made multiple recommendations to VA, including analyzing the declining number of completed root cause analyses and determining the extent VAMCs are using alternative processes to address adverse medical events. VA agreed with GAO’s recommendations.