Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.
This chart review study analyzed information from the Veterans Health Administration national database of root cause analyses to describe adverse events among veterans aged 65 years and older that resulted in sustained injury or death. Frequent incidents were falls, delays in diagnosis or treatment, and medication errors. Inadequate communication was the most common root cause identified in adverse events, and within this category, poor communication among providers (such as handoffs) often resulted in adverse events. Although virtually all root cause analyses led to implementation of action plans, only 40% were deemed effective. Compared to previous research, this study highlights robust use of root cause analysis while emphasizing the need for ongoing monitoring and improvement of corrective actions.