In fiscal year 2010, VA medical centers completed 1,862 root cause analyses. In fiscal 2014, that number dropped to 1,523. Veterans Health Administration officials are unsure why the drop in root cause analyses occurred.
Officials from the VHA’s National Center for Patient Safety suggested that the drop in root cause analyses occurred because VA hospitals could be using alternate processes to investigate medical errors. However, the GAO report notes that “Without understanding the extent to which [VA hospitals] use alternate processes and their results, NCPS has a limited awareness of what [VA hospitals] are doing to address the root causes of adverse events.”
The GAO recommended that the VA do the following to address the declining number of root cause analyses:
- Analyze the declining number of completed root cause analyses, including identifying the contributing factors of the decline and taking action
- Find the extent to which VA hospitals use alternate processes to address medical errors and collect information on those results
According to the GAO, the VA agreed with those recommendations.
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