Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

Book/Report

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

September 5, 2012

Washington, DC: United States Government Accountability Office; August 2012. Publication GAO-12-827R.

This report describes an analysis of incident reporting systems used in Veterans Health Administration medical centers to explore how the collected information is acted upon.

Summary

Free full text (PDF)

Related Resources From the Same Author(s)

Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.

August 15, 2012

DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers.

November 28, 2012

VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.

November 9, 2011

Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.

March 13, 2019

Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.

March 9, 2016

Approaches and Challenges to Electronically Matching Patients' Records Across Providers.

March 6, 2019

Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.

July 11, 2018

Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.

May 16, 2018

Actions Needed to Address Employee Misconduct Process and Ensure Accountability.

August 15, 2018

Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm.

November 22, 2017

Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.

December 6, 2017

Patient Options for Safe and Effective Disposal of Unused Opioids.

September 25, 2019

Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.

October 15, 2008

Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care.

May 4, 2016

Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.

July 20, 2016

Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.

February 24, 2016

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events.

September 9, 2015

Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.

March 19, 2014

Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.

February 19, 2014

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

January 19, 2022

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

May 27, 2020

VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.

January 15, 2014

Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.

April 29, 2020

Patient Safety Act.

February 10, 2010

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.

April 30, 2008

Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care.

December 9, 2020

VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.

July 5, 2006

VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities.

January 4, 2006

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

October 26, 2022

Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.

January 31, 2006

Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened.

July 12, 2006

VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.

July 5, 2006

Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns.

December 23, 2020

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

June 13, 2012

Patient Safety Measures: Complications.

January 30, 2005

National Voluntary Consensus Standards for Patient Safety Measures: A Consensus Report.

June 27, 2012

National Action Plan for Adverse Drug Event Prevention.

September 24, 2014

National Action Plan to Improve Health Literacy.

June 16, 2010

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

January 18, 2012

Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.

August 1, 2012

How Can Health Care Organizations Become More Health Literate?: Workshop Summary.

August 15, 2012

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Patient Safety as an Exercise in Behavioral Change.

October 24, 2012

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Oversight Hearing on Recent Patient Safety Issues.

June 28, 2006

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Safety Assurance Factors for EHR Resilience: SAFER Guides.

January 29, 2014

Drug Shortages: FDA's Ability to Respond Should Be Strengthened.

January 4, 2012

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.

December 12, 2018

Health IT Patient Safety Action and Surveillance Plan.

July 17, 2013

Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021.

October 18, 2023

Health IT Safety Center Roadmap.

July 29, 2015

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Medicare's Oversight of Ambulatory Surgery Centers Report.

October 23, 2019

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.

September 19, 2012

Health-Care–Associated Infections in Hospitals: Continuing Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections.

April 15, 2009

The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.

February 9, 2011

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

June 4, 2014

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Medication Management: Detailed Use Case.

July 4, 2007

Evidence Brief: Implementation of High Reliability Organization Principles.

July 24, 2019

Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention.

September 18, 2013

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

September 30, 2020

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

Clinician Well-Being Knowledge Hub.

April 4, 2018

NAM Action Collaborative on Clinician Well-Being and Resilience.

February 15, 2017

Patient Safety Measures.

December 11, 2013

Critical Deficiencies at the Washington DC VA Medical Center.

March 21, 2018

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee.

November 13, 2013

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

July 14, 2021

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota.

January 29, 2020

Safe Practices for Better Healthcare: 2010 Update.

April 21, 2010

Final Report of the Commission on Care.

August 3, 2016

Patient Safety 2015: Final Technical Report.

November 12, 2014

Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

August 10, 2022

Standardizing a Patient Safety Taxonomy.

February 22, 2006

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

January 14, 2015

Announcing 2009 Leapfrog top hospitals.

December 16, 2009

Partnership for Patients.

April 13, 2011

Identification and Prioritization of Health IT Patient Safety Measures.

March 16, 2016

The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse.

July 1, 2019

Core Entrustable Professional Activities for Entering Residency.

August 6, 2014

Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing.

August 9, 2017

Trends in Nursing Home Deficiencies and Complaints.

October 29, 2008

Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care.

October 5, 2016

Related Resources

Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee.

January 31, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

Hospital Reporting Program: Annual Summary.

December 27, 2023

National and State Healthcare-Associated Infections Progress Report.

November 30, 2023

NPSD Data Spotlight: Patterns of Fall Interventions.

November 15, 2023

Complaints to the Parliamentary and Health Service Ombudsman.

October 23, 2023

Maryland Hospital Patient Safety Program Annual Report.

September 28, 2023

Pediatric Diagnostic Safety: State of the Science and Future Directions.

September 13, 2023

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

Serious Reportable Events in Massachusetts.

May 22, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

National Diabetes Inpatient Audit -- Harms.

July 8, 2021

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

May 26, 2021

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Evidence Brief: Implementation of High Reliability Organization Principles.

July 24, 2019

Gosport War Memorial Hospital. The Report of the Gosport Independent Panel.

November 7, 2018

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits.

May 11, 2016

National Reporting and Learning System Research and Development.

April 13, 2016

Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.

March 9, 2016

Diagnostic experiences of children with attention-deficit/hyperactivity disorder.

September 30, 2015

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events.

September 9, 2015

Learning Not Blaming.

September 9, 2015

The Report of the Morecambe Bay Investigation.

April 29, 2015

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

January 14, 2015

America's Hospitals: Improving Quality and Safety: The Joint Commission's Annual Report 2014.

November 26, 2014

See More About The Topic

Hospitals

Health Care Executives and Administrators

General Internal Medicine

Hospital Medicine

Epidemiology of Errors and Adverse Events

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site