A report out late Friday from the Government Accountability Office found that the number of investigations of adverse events — the formal term for medical errors —plunged 18 percent from fiscal 2010 to fiscal 2014. The examinations shrank just as medical errors grew 7 percent over these years, a jump that roughly coincided with 14 percent growth in the number of veterans getting medical care through VA’s system.
Auditors said it was hard for them to know whether the decline in investigations (called root cause analyses) means that fewer errors are being reported, or that these mistakes, while on the rise, are not serious enough to warrant scrutiny.
But the reason for the caution is itself disconcerting: VA officials apparently have no idea why they are doing fewer investigations of medical errors. They told auditors that they haven’t looked into the decline or even whether hospitals are turning to another system.
The National Center for Patient Safety, the office in the Veterans Health Administration responsible for monitoring investigations of medical errors, “has limited awareness of what hospitals are doing to address the root causes of adverse events,” the report concluded.
Patient safety officials are “not aware of the extent to which these processes are used, the types of events being reviewed, or the changes resulting from them,” GAO wrote.
It added that “the lack of complete information may result in missed opportunities to identify needed system-wide patient safety improvements.”
Auditors said the lack of analysis is “inconsistent” with federal standards on internal controls, which require agencies to look at significant changes in data.
An adverse event is an incident that causes injury to a patient as the result of an intervention that shouldn’t have been made, or one that failed to happen, rather than the patient’s underlying medical condition. These kinds of errors are considered preventable, which is why hospitals and physicians are under pressure to put new systems in place or update their standards and procedures. They often result from a combination of system and medical errors.
Some examples: Medical equipment was improperly sterilized, leading a patient or multiple patients to be exposed to infectious diseases. Surgery was done on the wrong patient, with the wrong procedure on the wrong side. A patient falls or is burned. A patient gets the wrong medication or the wrong dose.
VA officials, in response to a draft of the report, generally agreed with its conclusions and with GAO’s recommendation that they get a better handle on why fewer root-cause investigations are done. The patient safety office has started a review that’s scheduled to be done in November. Officials acknowledged that while hospitals use other systems (such as the Six Sigma management method) to review medical errors, “these processes are not a replacement” for root-cause analyses.
The report was requested by three leading Senate Democrats and two House members who are ranking members or serve on committees that oversee VA, including presidential hopeful Bernie Sanders (I-Vt.); Sen. Richard Blumenthal (Conn.); Rep. Corrine Brown (Fla); Sen. Patty Murray (Wash.) and Rep. Eddie Bernice Johnson (Tex.)
Although they collected data from the entire system of 150 VA hospitals and clinics, auditors did a deeper dive at four: the Salt Lake City Health Care System; Robley Rex Medical Center in Louisville, Ky.; Southeast Louisiana Veterans Healthcare System in New Orleans and James E. Van Zandt Medical Center in Altoona, Pa.
Patient safety officials told auditors that while they haven’t done an analysis of why there are fewer investigations of medical errors, they observed a “change in the culture of safety” at many hospitals.
This is a revealing observation:
“[Patient safety] officials 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. 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 nonpunitive response to error.”
Still, the number of reports of medical errors has been increasing.
Root-cause analyses are launched depending on the severity of the error. High-risk mistakes that seem destined to recur require investigations. Lower-risk errors are up to the discretion of hospital staff.