VA Health Care:

Trends in Malpractice Claims Can Aid in Addressing Quality of Care Problems

HEHS-96-24: Published: Dec 21, 1995. Publicly Released: Dec 21, 1995.


David P. Baine
(202) 512-7101


Office of Public Affairs
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Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs' (VA) malpractice claims, focusing on the: (1) total number of malpractice claims filed against VA between fiscal years (FY) 1990 and 1994; (2) way VA manages its malpractice claims; (3) extent to which malpractice experiences are used in VA quality assurance activities; and (4) volume of non-VA health care malpractice claims.

GAO found that: (1) between FY 1990 and 1994, malpractice claims against VA medical centers (VAMC) increased from 678 to 978 annually and claimants received over $205 million in payments; (2) in 1992, VA entered into an agreement with the Armed Forces Institute of Pathology (AFIP) to analyze malpractice claims on a systemwide basis to identify malpractice trends and risk management issues, but VA is not using the information requested from AFIP to address risk management or quality assurance issues; (3) although Department of Defense (DOD) malpractice data can not easily be compared to VA data due to the lack of a standard data collection format, comparisons can be made of the types of problems resulting in malpractice claims against each agency; and (4) DOD malpractice data may help VA identify areas in which malpractice claims are being generated, such as surgery-related incidents.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendation for Executive Action

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to require VAMC directors to obtain and utilize all available AFIP data, including facility-specific data to: (1) identify problem-prone clinical processes; and (2) initiate programs to prevent recurrence of adverse events that caused malpractice claims to be generated.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: VA agrees with the report findings and concurs with the recommendation. VA notified all medical centers of the availability of AFIP data, established a physician medical/legal consultant position to manage the review of tort claims for all Regional Counsel offices, and educated VAMC quality management staff about the capabilities of AFIP in identifying malpractice trends and risk management issues.

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