<--GAT-->
Agencies

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.


Related Articles

Rural Veterans With MS Benefit from Clinical Video Telehealth Rehabilitation

Of the more than 28,000 veterans with multiple sclerosis (MS) who receive care at the VHA, almost 45% of them live in rural or highly rural areas, a recent conference presentation pointed out.

Flu Vaccination Rates Up for VA Health Care Staff, But Still Lag National Average

While the VA significantly lags behind other healthcare systems in mandating influenza vaccinations for healthcare workers, according to recent research, it is moving closer to the national average because of a directive issued last fall.


U.S. Medicine Recommends


More From department of defense dod

Department of Defense (DoD)

Automation Speeds Results and Increases Accuracy for Point-of-Care Testing at Walter Reed NMMC

With a long history of point of care testing at both of its predecessor organizations, the Walter Reed National Military Medical Center (WRNMMC) laboratory services staff were keenly aware of the advantages of using portable testing devices to obtain rapid patient assessments.

Department of Defense (DoD)

High Rate of Pectoralis Tears Among Deployed Servicemembers Lifting Weights

Lifting weights is one way servicemembers keep in peak physical condition during deployment.

Department of Defense (DoD)

DoD Study Finds That Type 2 Diabetes Increases Breast Cancer Mortality

Having Type 2 diabetes mellitus (DM-2) increases mortality risk in breast cancer patients, regardless of whether diabetes was diagnosed before or after breast cancer, according to a recent study.

Department of Defense (DoD)

Now Hear This: Otolaryngologist Leads Effort to Prevent Auditory Issues

Among those who are exposed to combat, it’s the weapons fire that does it. In the Navy, it’s the noise levels in engine rooms and on the decks of carriers.

Department of Defense (DoD)

GAO: ‘Gaps’ in MHS Physician Specialties Could Affect Wartime Readiness

WASHINGTON — The military services need to develop “targeted and coordinated strategies” to alleviate military physician gaps, a recent report recommended.

Facebook Comment

Subscribe to U.S. Medicine Print Magazine

U.S. Medicine is mailed free each month to physicians, pharmacists, nurse practitioners, physician assistants and administrators working for Veterans Affairs, Department of Defense and U.S. Public Health Service.

Subscribe Now

Receive Our Email Newsletter

Stay informed about federal medical news, clinical updates and reports on government topics for the federal healthcare professional.

Sign Up