VA Hospitals Failing to Investigate Medical Errors, GAO Finds

They Don't Know Why and Don't Seem to Care

VA Hospital Provides Amputees With Prosthetics
VA Hospital Provides Amputees With Prosthetics. John Moore/Getty Images

The Department of Veterans Affairs is doing less, rather than more, to identify and eliminate the causes of preventable medical errors at VA hospitals, according to a top federal watchdog agency.

In a report dated July 2015, the Government Accountability Office (GAO) found that while the number of medical errors that pose a risk of injury to patients in VA facilities has increased by 7% since fiscal year 2010, the number of such medical errors being investigated by the VA has actually decreased by 18%.

At the same time, the number of veterans getting treatment in VA health facilities has increased by 14% since 2010.

The GAO’s auditors were not able to determine the exactly why the number of medical errors being investigated has decreased so drastically. Possible reasons cited by the GAO included fewer errors that occur are being report as required, or that the VA medical staffs do not consider the errors serious enough to warrant official investigations.

VA Doesn’t Seem to Know or Particularly Care Why

The scary part is that the VA officials told the GAO that they had no idea why fewer investigations of medical errors are being done and had frankly not even looked for a reason.

According to the GAO’s report, the National Center for Patient Safety, the branch of the VA responsible for tracking medical errors and investigations of them, “has limited awareness of what hospitals are doing to address the root causes of adverse events.”

“Moreover, the lack of complete information may result in missed opportunities to identify needed system-wide patient safety improvements,” wrote the GAO.

The term “adverse events” is VA-speak for preventable medical errors or incidents “that pose a risk of injury to a patient as the result of a medical intervention or the lack of an appropriate intervention, such as a missed or delayed diagnosis.”

A few examples of preventable adverse events include infections due to poor sterilization, incorrectly prescribed or administered medications, and procedures performed on the wrong patient.

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The VA decides whether to perform an investigation, or “root-cause analysis,” of adverse events based on the severity of the medical error involved. The more likely it is that the error could result in the injury of a patient; the more likely it is to be investigated, according to the GAO.

In doing its investigation, the GAO collected data on medical errors from all 150 VA hospitals, focusing especially on the Salt Lake City Health Care System; Robley Rex Medical Center in Louisville, Kentucky; Southeast Louisiana Veterans Healthcare System in New Orleans and James E. Van Zandt Medical Center in Altoona, Pennsylvania.

A Disturbing Change in VA’s 'Culture of Safety'

While the VA medical safety officials interviewed by the GAO may not have know why fewer medical errors are being investigated, they had noticed a disturbing “change in the culture of safety” at VA hospitals.

“[O]fficials stated that they have observed a change in the culture of safety in recent years in which staff feel less comfortable reporting adverse events than they did previously.”

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Officials added that “this change is reflected in [their] periodic survey on staff perceptions of safety; specifically, 2014 scores showed decreases from 2011 on questions measuring staff’s overall perception of patient safety, as well as decreases in perceptions of the extent to which staff work in an environment with a non-punitive response to error.”

What the GAO Recommended

The GAO recommended that the VA try to find out why the number of preventable, dangerous medical errors being investigated at VA hospitals is decreasing at a time when the number of such errors is increasing. 

The VA “generally” agreed and committed to completing an analysis of the situation by the end of November 2015.