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VA Health Care: VA's Patient Injury Control Program Not Effective

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Report Type Reports and Testimonies
Report Date May 18, 1987
Report No. HRD-87-49
Subject
Summary:

Pursuant to a congressional request, GAO reviewed the effectiveness of the patient injury control function in the Veterans Administration's (VA) quality assurance program.

At the nine centers GAO visited, it found that: (1) the patient injury control program was not effective in preventing the recurrence of unexpected deaths and surgical complications; (2) in fiscal year (FY) 1985, VA medical centers reported about 85,000 incidents involving patient injuries, but did not report more serious injuries because of staff disincentives, lack of central oversight, and inadequate reporting guidelines; (3) VA referred only 36 percent of the incidents requiring investigation to the medical inspector; (4) VA did not compare data on patient incidents over time because it thought that it would take care of the incidents on a case-by-case basis or by other quality assurance activities; and (5) an occurrence screening program would complement the incident-reporting program.

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