Why Is Little Being Done About Medical Errors Occurring At VA Hospitals?

2015-09-02T13:27:32-04:00

An Aug. 28 report from the Government Accountability Office reveals that hospitals within the Veterans Affairs system may be doing less than they should to investigate preventable medical mistakes.

The report found that the number of investigations for medical errors, called “adverse effects,” plunged 18% between 2010 and 2014. As the number of examinations shrank, medical errors grew 7% during those same years. At the same time, the number of veterans seeking medical care through the VA grew by 14%. Last year alone, roughly 5.8 million people sought care at VA medical hospitals.

In essence, more veterans are seeking care while the number of medical mishaps increases.

http://www.washingtonpost.com/blogs/federal-eye/wp/2015/08/31/medical-errors-are-up-at-va-hospitals-but-theyre-actually-doing-less-to-figure-out-why/

Medical errors are up at VA hospitals, but they’re actually doing less to figure out why

VA officials told auditors they don't know why hospitals are doing fewer investigations of preventable medical errors.

Response by SCPO David Lockwood made Sep 2 at 2015 1:28 PM

2015-09-02T13:28:50-04:00

Government run.

Response by Sgt Spencer Sikder made Sep 2 at 2015 1:57 PM

2015-09-02T13:57:41-04:00

Maybe because the good staff left VA as outlined in the OIG report.

Response by CW3 Kevin Storm made Sep 2 at 2015 1:58 PM

2015-09-02T13:58:48-04:00

I am going to cry foul, to be sure every single VA facility can tell you the reason why. We are no different than any other health care system. We have to be accredited by the Joint Commission (TJC), if we have a rehabilitation program at our facility, each program has to be Commission on Accreditation of Rehabilitation Facilities (CARF). That doesn't include all the internal evaluations from the Central Office VA and regional offices. So if some one is saying they don't know I don't believe them, as the data is there for the TJC and CARF. I suspect there is either a very ignorant staff member or some serious politics at play here. Are we perfect, no, but by no means are we incompetent. I would put my facility against a lot of private facilities that do the same thing. If we have issues, trust me it is being tracked, there is a corrective action plan in place, and it is being followed up on. For the record the VA Palo Alto Health Care System has over 40% Veterans as employees, and yes we give a damn about our brothers and sister veterans!

Response by SGT Mark Stevens made Sep 2 at 2015 2:15 PM

2015-09-02T14:15:52-04:00

It's cheeper to pay for the major mishaps when they have to then to continue to pay for the mishap prevention.

Response by SFC Dennis Yancy made Sep 2 at 2015 2:16 PM

2015-09-02T14:16:12-04:00

Unions protect workers, management prefers not to cause issues and do jobs correctly, is just a job. I discovered that VA always turns down packets almost always. Turns out VA workers were given bonuses if they processed so many packets. Sure that practice has been stopped but never know.

Response by PFC Donnie Harold Harris made Sep 2 at 2015 2:24 PM

2015-09-02T14:24:25-04:00

The VA has a real hard time with Emotional Intelligence. They badger instead of advice. but worst of the worst, And why I say overall, the VA has very little consideration and give "careless care", Is their refusal to call or communicate with the patient after a Vital Test or Procedure. 0 Nothing. No calls. They say if we do not call that is good. I say If you do not call that is good for you maybe. But not good for me or Other family members that will have concerns after the Test you did. We are all left in confusion and doubt for up to 6 months while waiting to recycle back to see the primary care doctor again. If the VA want to Improve Service to the veterans, while cutting down costs on care, Talk to the Patient In front of You. Or call him at home when someone else can help with questions. The Placebo effect can work in reverse and make you sick when you are not because of doubtful care.

Response by CPT Private RallyPoint Member made Sep 2 at 2015 2:37 PM

2015-09-02T14:37:46-04:00

The VA is so overwhelmed, they "don't know were to start." If and I do mean if, the VA has a plan of action, the aren't working it.
Who is "holding their feet to the fire"?

Response by PO3 Steven Sherrill made Sep 2 at 2015 2:55 PM

2015-09-02T14:55:34-04:00

SGT Private RallyPoint Member add it to the very long list of things that need to be fixed at the VA.

I am still convinced that their idea of fixing things is health care by attrition. Keep em waiting long enough they die from their ailment, and we don't have to worry about it. This is just another step in that direction. Keeping em waiting not working? Mess up the procedures so they die from that, then we don't have to worry about it.

This is a horrible thing to say about an organization whose sole purpose is caring for veterans, but it is how I feel about them.

Response by LCDR Rabbah Rona Matlow made Sep 2 at 2015 3:07 PM

2015-09-02T15:07:46-04:00

It has to do with demand. When demand outsteps provider supply, error rates go up, because providers are overworked. Complicating this is a huge shortage of doctors because of the cost of college these days. Until all these issues can get sorted, and read $$$$$ here, these problems will continue...

Response by MCPO Roger Collins made Sep 2 at 2015 3:23 PM

2015-09-02T15:23:20-04:00

I often wonder what the purpose of the GAO and the various agency IGs is since no one seems to pay attention to their reports. If you follow the VAIG's reports, most of these things are identified and reported for action (including action recommendations). Therein lies my issues with government.

Response by CPT Private RallyPoint Member made Sep 2 at 2015 6:30 PM

2015-09-02T18:30:09-04:00

SGT Private RallyPoint Member This isn't about the V.A. it's about the doctors, nurses, and other medical staff at the V.A.. The place to look for answers is in the medical review boards. What did the review boards find? If there is evidence the V.A. facilities are being ran without review boards the blame belongs to the Chief Operating Officer for not ensuring every case where an error is claimed to have happened is being reviewed.