Veterans Health Care:

Veterans Health Administration Processes for Responding to Reported Adverse Events

GAO-12-827R: Published: Aug 24, 2012. Publicly Released: Aug 24, 2012.

Additional Materials:


Debra A. Draper
(202) 512-3000


Office of Public Affairs
(202) 512-4800

What GAO Found

Through its policy and guidance, VHA has outlined processes that enable VAMCs to respond to reported adverse events that occur. VHA generally grants individual VAMCs discretion on choosing which process to use. Specifically, VAMCs conduct an initial review to determine how best to respond to an adverse event. According to VHA officials, if the circumstances that led to an adverse event are clear, based on a VAMC's initial review, VAMCs can take immediate corrective action. If the circumstances that led to an adverse event need to be examined further, VAMCs are given discretion to use one or more of the following four processes: (1) root cause analysis, (2) peer review, (3) clinical care review, and (4) administrative investigation board. Because VAMCs generally have discretion in which of these processes they use, different VAMCs that experience similar adverse events may not use the same processes to respond to them. Nonetheless, each process has certain purposes and limitations. For example, some of these processes may be used to examine a clinician's actions as they relate to an adverse event, while others may be used to examine whether a systems or process issue exists. Furthermore, information collected through two of these processes--clinical care reviews and administrative investigation boards--can be used to inform actions against clinicians; information collected using root cause analyses and peer reviews cannot be used to support such actions, because information collected under those processes is protected and confidential, under federal law. Based on the nature of an adverse event and the information gleaned through a particular review process, a VAMC may decide to conduct multiple types of reviews, as appropriate.

Why GAO Did This Study

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. 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 events--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 condition--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. VHA policy requires that appropriate action be taken to evaluate reported adverse events. 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 admonishments to termination of employment; as well as actions taken to limit a clinician's clinical privileges, such as the reduction or revocation of privileges. 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. Recent adverse events have raised questions about the quality of care provided to veterans by VAMCs, and whether lessons learned at one VAMC are being translated into systemwide improvements. In response, members of Congress have raised questions as to the processes VHA has in place to respond to adverse events at VAMCs and take appropriate action, when needed, to address problems found within the VHA health care system. Congress asked us to describe how VHA responds to reported adverse events within its health care system. In this report, we describe VHA's processes for responding to reported adverse events within its health care system. In future work, we will examine the implementation of these processes at VAMCs.

For information, contact Debra A. Draper at (202) 512-7114 or

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