GAO Report Outlines VA’s Four-Part Response to Adverse Events

Healthcare risk managers may be interested in a recent U.S. Government Accountability Office (GAO) report that describes the process for responding to adverse events at medical centers operated by the Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA). The report was requested by the House and Senate Committees on Veterans Affairs in response to adverse events that have raised questions about the quality of care provided at VA medical centers and concerns that the lessons learned at one center may not be shared with others to ensure systemwide improvements. VHA provides guidance to its medical centers for responding to adverse events (including near misses or close calls) and, generally, grants its medical centers discretion in choosing which process to use. If the circumstances that led to the adverse event require further examination, the medical centers are instructed to use one or more of the following four processes: 1) root cause analysis to identify systemic causes of adverse events, particularly those with a high likelihood of recurring ; 2) peer review to determine if a clinician’s actions associated with an adverse event were clinically appropriate;