As VA medical errors increased, investigations went down

Medical errors, the third-leading cause of death in the United States, are up at Veterans Affairs (VA) facilities, but the department is spending less time investigating what caused those errors, according to a new report from the Government Accountability Office (GAO).

Between fiscal  years 2010 and 2014, medical errors grew 7 percent, according to the report. However, during the same period, investigations or root cause analyses (RCA) of adverse events--fell 18 percent. The decline could mean fewer errors are being reported, according to the GAO, or that the mistakes that make up the increase are not serious enough to warrant full investigations.

Officials with the VA's National Center for Patient Safety, meanwhile, told GAO auditors they hadn't done any investigation into the decline. They suggested to auditors that it could be due to VA hospitals' use of different types of investigations than RCAs, but conceded they had no knowledge of which hospitals used alternate processes. Therefore, it's unclear whether the decrease indicates a negative trend in patient safety at VA facillities or a positive one, the report noted. 

Patient safety officials did, however, note shifts in the "culture of safety" at many VA facilities, according to the report. Staff seem to feel less comfortable than before reporting adverse events, and surveys on staff perceptions of safety reflect the shift, with 2014 scores on overall safety and perceptions of how safe it is to report an error both down significantly from 2011. Complaints of retaliation against whistleblowers have been common since the initial VA scandal broke last spring, and the department settled with three VA employees in late July.

To learn more:
- read the report (.pdf)

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