What's Behind the Drop in Studies of VA Adverse Events?


Quality may be getting better, but the GAO was not pleased that the VA did not have a handle on the drop-off in evaluations.

Is the quality of healthcare at Veterans Administration (VA) medical centers improving so much that we can have fewer studies of mistakes? Or this there some other reason the number of studies into things that go wrong has dropped in the past 5 years?

The Government Accountability Office (GAO) looked into this question and on Friday issued a report that could not come up with a firm reason why a key examination of healthcare quality—the “root cause analysis” or RCA—is becoming less common at the VA. This is happening even through reports of adverse events are climbing, up 7% over the same years in question, 2010 to 2014.

An RCA is required if the initial review uncovers a safety lapse that is severe enough that it could pose a danger to other patients in the future. Aggregated RCAs are required at each facility on 3 types of events each year: falls, adverse drug events, and missing patients. Data reported by the GAO found the number of RCAs dropped from 1862 in 2010 to 1523 in 2014.

According to the GAO, the VA’s lack of analysis doesn’t square with federal internal control standards that govern when agencies should flag such trends and take action. So the GAO is calling on the VA to do just that, especially in light of the many other document issues at the agency in the past 5 years, notably delays in veterans receiving care.

The GAO was troubled by the fact that the VA’s National Center for Patient Safety knew about the drop-off in RCA’s but did not know why this had occurred.

There could be some legitimate reasons why there are fewer such reports, and it could even mean that quality of care is improving. The VA has instituted many other quality care measures that could be taking over the RCA process. But the GAO remained troubled that there did not seem to be a firm handle on why the drop-off in reporting had occurred.

GAO called for the following:

· The VA should analyze the declining number of RCAs and identify the contributing factors for the decline.

· The VA should determine if other parts of the healthcare system are addressing adverse events, and gather information on these results.

The agency agreed with both recommendations.

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