DoD acknowledges its medical adverse event reporting is ‘unreliable’

by Sandra Basu

June 22, 2018

WASHINGTON — The process for tracking the DoD’s most serious adverse medical events is “fragmented, impeding the Defense Health Agency’s (DHA) ability to ensure that it has received complete information,” according to a new review.

“Each year, thousands of adverse medical events are reported at MTFs. Tracking and conducting follow-up on these events is crucial for officials to learn from and prevent these events in the future,” the document stated, noting problems with root cause analysis (RCA) reports.

The finding was part of a recent Government Accountability Office (GAO) report that recommended that the DHA should improve the tracking of serious adverse events and clarify its requirements for submitting reports on the implementation of corrective actions.

“DHA cannot ensure that it is receiving all reports on the implementation of corrective actions, such as Measures of Success (MOS) reports, and does not know how many reports it is missing for a number of reasons, including those related to policy, tracking, and reconciliation efforts,” GAO authors wrote. “Collectively, all of these information gaps impair DHA’s ability to fully understand the types of sentinel events that are occurring in its MTFs, the corrective actions that have been implemented, and whether these actions have been effective.”

In 2015, DoD redefined its definition of a sentinel event to be a patient safety issue that results in death, permanent harm or severe temporary harm. Prior to that, a sentinel event was considered to be an unexpected occurrence involving death or serious physical or psychological injury or risk.

From 2013 through 2016, DHA’s data showed an increase in the total number of reported medical and dental sentinel events from 121 to 319.

“Medical sentinel events approximately doubled from 101 to 206, while dental sentinel events increased more than fivefold from 20 to 113,” the report pointed out, suggesting, “The sharp increase in events in 2015 may have been influenced by DHA’s revised definition of sentinel events, as well as the Army’s inclusion of dental events that meet sentinel event criteria.”

Currently, MTF staff enter adverse event information into DHA’s Joint Patient Safety Reporting system (JPSR). Sentinel events require some additional reports that the JPSR does not have the capability of tracking, however. As a result, MTFs create tracking records of sentinel events. The reports are then transmitted via email to DHA, where they are manually entered into a tracking record.

Because the process used to track sentinel events and RCA reports is fragmented, DHA officials said they rely on their reconciliation process to ensure they have complete information, according to the GAO report.

“DHA officials acknowledged that their reconciliation process is inefficient and told us that their full-time employees and contractors spend an average of 80 hours per month working on it,” the review stated. “Additionally, officials told us that sometimes information about sentinel events and RCA reports is lost or not effectively communicated due to complexities related to routing the email submissions and to turnover in the contract staff who track and reconcile this information.”

The GAO also noted that it found “discrepancies” in the number of RCA reports when comparing DHA’s internal tracking record to the military services’ and internal tracking records from the National Capital Region (NCR).

“In some instances, we found that DHA had more RCA reports in its tracking record than the military services or NCR for reported sentinel events, and in other instances, DHA had fewer RCA reports in its tracking record than the military services or NCR,” the report stated.

The GAO pointed out that, as part of the patient safety activities, DHA officials will assume responsibility for adverse medical event reporting beginning Oct. 1, 2018, and that, as “MTF patient safety responsibilities are transitioned to DHA, the fragmented tracking process may hamper DHA’s ability to efficiently and effectively monitor sentinel events and RCA reports, potentially leading to missed opportunities for systemic improvement.”

In response to the recommendations, DoD “acknowledged that its current tracking efforts for sentinel events and RCAs are fragmented, inefficient and unreliable.”

In the future, DoD responded that “it envisions a single system to track and monitor sentinel events, RCAs, and corrective action implementation plan reports.”

“A single system would eliminate the fragmentation associated with tracking these reports and the need for a cumbersome reconciliation process, potentially improving the completeness and reliability of DHA’s patient safety data as well as its ability to identify and implement system-wide improvements,” GAO explained.

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