Accession Number:



DOD Health Care: Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up

Descriptive Note:

[Technical Report, Congressional Report]

Corporate Author:

United States Government Accountability Office

Personal Author(s):

Report Date:


Pagination or Media Count:



Adverse medical events are unintended incidents that may harm a patient. Serious adverse medical events, called sentinel events, have specific follow-up requirements. The National Defense Authorization Act for Fiscal Year 2017 NDAA 2017requires DHA to assume the military services administrative responsibilities, such as adverse medical event reporting, for all MTFs beginning October 1, 2018.The NDAA 2017 included a provision for GAO to examine the reporting and resolving of adverse medical events in the military health system. Among other objectives, this report reviews 1 the extent to which sentinel events and RCA reports are tracked and DHA ensures it has received complete information, and2 the extent to which DHA ensures it has received MOS reports. GAO examined relevant policies analyzed the most current available data on sentinel events from 2013 through2016 and interviewed officials with DHA, the military services, and four MTFs selected for variety in military service, size, and geographic location.


Subject Categories:

  • Medicine and Medical Research

Distribution Statement:

[A, Approved For Public Release]