Adverse Events:
Surveillance Systems for Adverse Events and Medical Errors
T-HEHS-00-61: Published: Feb 9, 2000. Publicly Released: Feb 9, 2000.
Additional Materials:
- Full Report:
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Pursuant to a congressional request, GAO discussed its report on issues related to adverse medical events in the nation's health care system.
GAO noted that: (1) the results of GAO's work have important implications for addressing adverse medical events including the design of surveillance systems to detect adverse events and medical errors; (2) while adverse events have been recognized as a serious problem, the full magnitude of their threat to the health of the American public is unknown; (3) gathering valid and useful information about adverse events is extremely difficult; (4) all systems that rely on health care providers to take the initiative to make a report--known as passive or spontaneous reporting systems--have serious limitations; (5) this is true whether or not providers are legally required to report adverse events; (6) both mandatory and voluntary spontaneous reporting systems share this limitation; (7) many of the injuries patients suffer as a result of medical treatment do not stem from errors but reflect the inherent risks of treatments that are administered correctly; and (8) it can be difficult both to identify these adverse reactions and distinguish them from medical errors or from the course of a patient's underlying illnesses.
Jan 14, 2021
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Medicaid:
Data Completeness and Accuracy Have Improved, Though Not All Standards Have Been MetGAO-21-196: Published: Jan 14, 2021. Publicly Released: Jan 14, 2021.
Jan 4, 2021
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Medicare Severe Wound Care:
Spending Declines May Reflect Site of Care Changes; Limited Information Is Available on QualityGAO-21-92: Published: Jan 4, 2021. Publicly Released: Jan 4, 2021.
Dec 22, 2020
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Defense Health Care:
Efforts to Ensure Beneficiaries Access Specialty Care and Receive Timely and Effective CareGAO-21-143: Published: Dec 22, 2020. Publicly Released: Dec 22, 2020.
Dec 16, 2020
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Medicaid Long-Term Services and Supports:
Access and Quality Problems in Managed Care Demand Improved OversightGAO-21-49: Published: Nov 16, 2020. Publicly Released: Dec 16, 2020.
Dec 14, 2020
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Drug Pricing Program:
HHS Uses Multiple Mechanisms to Help Ensure Compliance with 340B RequirementsGAO-21-107: Published: Dec 14, 2020. Publicly Released: Dec 14, 2020. -
Substance Use Disorder:
Reliable Data Needed for Substance Abuse Prevention and Treatment Block Grant ProgramGAO-21-58: Published: Dec 14, 2020. Publicly Released: Dec 14, 2020.
Dec 10, 2020
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Indian Health Service:
Actions Needed to Improve Oversight of Provider Misconduct and Substandard PerformanceGAO-21-97: Published: Dec 10, 2020. Publicly Released: Dec 10, 2020. -
Clinical Labs:
Studies Suggest Biopsy Specimen Misidentification and Contamination Errors Are InfrequentGAO-21-59: Published: Nov 10, 2020. Publicly Released: Dec 10, 2020.
Dec 7, 2020
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Medicaid:
CMS Needs More Information on States' Financing and Payment Arrangements to Improve OversightGAO-21-98: Published: Dec 7, 2020. Publicly Released: Dec 7, 2020.
Dec 1, 2020
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Military Health Care:
Defense Health Agency Processes for Responding to Provider Quality and Safety ConcernsGAO-21-160R: Published: Dec 1, 2020. Publicly Released: Dec 1, 2020.
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