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Accession Number:
ADA621102
Title:
VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events
Descriptive Note:
Congressional rept.
Corporate Author:
GOVERNMENT ACCOUNTABILITY OFFICE WASHINGTON DC
Report Date:
2015-07-01
Pagination or Media Count:
29.0
Abstract:
Adverse events are incidents that pose a risk of injury to a patient as the result of a medical intervention or the lack of an appropriate intervention. VAMCs use the RCA process to identify and evaluate systems or processes that caused an adverse event, recommend changes to prevent the event s recurrence, and determine whether implemented changes were effective. GAO was asked to review VA s processes and procedures for responding to adverse events. In this report, GAO examined 1 the extent to which VAMCs used the RCA process to respond to adverse events and 2 how VHA oversees the RCA process and uses information from the process to make system-wide improvements. To conduct this work, GAO reviewed VHA policy and guidance documents, analyzed VHA data on RCAs completed from fiscal years 2010 through 2014, and interviewed officials from NCPS the VHA office responsible for monitoring RCA data. GAO also analyzed local RCA data and interviewed officials from four VAMCs selected to provide variation in factors such as complexity and location. GAO recommends that VA 1 analyze the declining number of completed RCAs, including identifying the contributing factors and taking appropriate actions, and 2 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.
Distribution Statement:
APPROVED FOR PUBLIC RELEASE
