The Veterans Affairs Department is conducting fewer reviews of medical errors, even though the number of such problems has increased, according to a report by the U.S. Government Accountability Office.
The VA said it is aware of the decrease in reviews, but has not studied why it has happened. Without a reason, the GAO authors wrote, it is not clear whether the trend is bad for patient safety.
The report recommends the VA analyze the decrease to identify contributing factors and assess whether other methods are being used to address adverse events. The VA, still reeling from last year's cover up of wait times, agreed in an included response.
The study looks at data from all 150 VA hospitals and clinics.
The medical centers conducted 18% fewer root cause analyses of adverse events in fiscal 2014 than in fiscal 2010. The number of such events, however, increased 7% from 109,951 in 2010 to 117,136 in 2014, according to the report.
Hospitals perform root cause analysis to determine what causes an adverse event and what could be done to prevent future similar events. The Veterans Health Administration National Center for Patient Safety uses the results of the reviews to develop systemwide patient-safety initiatives.
NCPS officials have noticed that hospital staff feel less comfortable reporting errors than they previously did and staff also rated patient safety as lower in 2014 than 2011, according to the report.
In a written response to the report, the VA said it has already begun evaluating why there have been fewer analyses and has incorporated the number of safety reports per 10,000 patients in the criteria that determines whether a facility receives a bronze, silver or gold rating.
“This design encourages increased reporting of events, which in turn should increase the number of RCAs chartered and completed,” according to the response.
The report was requested by three leading Senate Democrats and two House members who are ranking members or serve on committees that oversee the VA, including presidential hopeful Bernie Sanders (I-Vt.).
