Key Issues > Duplication & Cost Savings > GAO's Action Tracker > DOD Adverse Medical Events (2019-08)
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Health: DOD Adverse Medical Events (2019-08)

The Department of Defense needs to improve the systems and processes it uses to track the most serious adverse medical events to reduce and better manage fragmentation, fully understand why such events occurred, and identify what actions are needed to prevent similar incidents.

Action:

The Assistant Secretary of Defense for Health Affairs should ensure the Defense Health Agency (DHA) improves as appropriate the systems and processes used by the military services, National Capital Region (NCR), and DHA to track sentinel events and root cause analysis (RCA) reports and require the military services and NCR to communicate with DHA the reasons RCA reports are not completed for reported sentinel events.

Progress:

The Department of Defense agreed with and has partially addressed this action, as recommended by GAO in April 2018. In December 2019, DOD reported that it has implemented a military service and NCR-wide standardized sentinel event reporting template and has begun developing a standardized RCA reporting template. Additionally, DOD reported that it is exploring a resources and acquisition strategy for a comprehensive and integrated adverse event management system to be implemented in 2021. Successful implementation of a centralized system for sentinel events and their associated follow up reports would help DOD to ensure it has complete information about the most serious medical events occurring in its facilities and help prevent them from occurring in the future.

Implementing Entity:

Department of Defense