Government Report Reveals Rise in VA Medical Errors but Decrease in Investigations
Oct 30, 2015
Northville, MI (Law Firm Newswire) October 30, 2015 – The number of medical errors at hospitals run by the Department of Veterans Affairs (VA) has increased over a four-year period, but the VA has conducted fewer investigations into what caused them.
According to a Government Accountability Office (GAO) report released on Aug. 28, the number of adverse events — the formal term for medical errors — at VA hospitals increased by seven percent between the fiscal years 2010 and 2014. The same period saw the root cause analysis (RCA) of adverse events drop by 18 percent, coinciding with a 14 percent increase in the number of patients.
“The VA has already been dealing with a number of problems related to long wait times for veterans seeking health care. This latest report indicates yet again that the department should get to the bottom of what is happening in its hospitals. Veterans have the right to feel safe when using VA facilities,” said Jim Fausone, a Michigan-based veterans attorney.
Auditors were unable to determine whether fewer investigations meant a decline in errors being reported, or that the mistakes were not serious enough to warrant examination. The National Center for Patient Safety as part of the Veterans Health Administration office is responsible for overseeing investigations of medical mistakes across the VA’s system of 150 hospitals and clinics. In the report, GAO wrote that patient safety officials were unaware of “the types of events being reviewed, or the changes resulting from them.” It added, “The lack of complete information may result in missed opportunities to identify needed system-wide patient safety improvements.”
GAO recommended the VA investigate the decline in RCAs. The report also noted that VA hospital staff claimed they felt less comfortable reporting medical errors and rated patient safety lower in 2014 than in 2011. VA officials said they are aware of the decline in reviews, but do not know why fewer investigations are taking place. In a written response to the report, the department said it has begun evaluating the reason behind the decrease.
“VA hospitals should put new systems in place to reduce the number of preventable medical errors, such as improperly sterilized medical equipment or surgery conducted on the wrong patient. Medical errors could not only cause irreversible harm, but could also result in the death of patients,” said Fausone.
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