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- Governmental Reporting
- Transparency and Accountability
Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
Adverse event reporting is an important step toward failure reduction. However, weaknesses in feedback, follow-up, and action resulting from incident reports diminish their impact on safety. This publication analyzed reporting activity and action in the Defense Health Agency. The resulting recommendations suggest the need to improve tracking of incident reports and for clarifying reporting requirements.
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.
Tracking concerns related to individual clinician performance has the potential to uncover opportunities for clinician skill and system safety enhancements. This report highlights weaknesses in the peer reporting processes of Veterans Affairs medical centers and offers recommendations to improve the quality and timeliness of reporting to ensure safety of patients in the VA system.
The Quality Improvement Committee. Wellington, New Zealand.
Considered a starting point for a national reporting initiative, this series of annual reports provides statistics on serious and sentinel events in New Zealand's 21 District Health Boards. The reports aim to encourage transparency in New Zealand medical practice and bolster knowledge to prevent future errors.
St. Paul, MN: Minnesota Department of Health; January 2009.
Through a qualitative evaluation of the Minnesota statewide reporting initiative, this report suggests ways to improve the reporting system to facilitate continued learning and transparency.