Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events
Abstract
The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) operates one of the largest health care delivery systems in the United States, providing care to more than 6 million veterans annually. Organized into 21 Veterans Integrated Service Networks, VHA s health care system includes 152 Veterans Affairs medical centers (VAMC) nationwide that offer a variety of outpatient, residential, and inpatient services.1 These health care services are delivered by physicians, dentists, and other providers and range from routine examinations to complex surgical procedures. During the course of providing health care services, adverse events2 clinical incidents that may pose the risk of injury to a patient as the result of a medical intervention or lack of an appropriate intervention, such as a missed or delayed diagnosis, rather than that patient s underlying medical condition3 may occur, resulting in potential harm to veterans. They are required to be reported to appropriate VAMC staff through each facility s incident reporting system, or through other channels, such as anonymous phone calls or e-mails to VAMC staff, such as the patient safety manager or risk manager, according to officials.5 VHA policy requires that appropriate action be taken to evaluate reported adverse events.6 Once an adverse event has been evaluated, the VAMC may take actions that include correcting system or process issues and taking actions against individual clinicians when warranted. Specifically, actions taken against individual clinicians following adverse events may include adverse actions ranging from admonishments7 to termination of employment; as well as actions taken to limit a clinician s clinical privileges, such as the reduction or revocation of privileges.8 Staff remediation activities, such as refresher training and proctoring, can be employed when adverse actions or limiting a clinician s privileges are not deemed necessary.
Document Details
- Document Type
- Technical Report
- Publication Date
- Aug 24, 2012
- Accession Number
- ADA563786
Entities
Organizations
- United States Government Accountability Office