Medical mistakes at Department of Veterans Affairs hospitals keep increasing, and medical staff are doing less and less to investigate the root causes of these errors, according to a new government watchdog report.
The report from the Government Accountability Office found that from fiscal years 2010 to 2014, investigations into medical errors dropped by a total of 18 percent. Medical errors have grown by 7 percent during that same period, which can partly be explained by the massive growth in veterans receiving care from the VA, following troop withdrawals in Iraq and Afghanistan.
The medical errors are formally labeled as adverse events, and some of these events can include patients receiving the wrong medication, or more serious examples where surgery is performed on the wrong person and for the wrong condition.
It isn’t completely clear what is causing the decline in investigations, though it may be because officials deem many of the mistakes as too trivial to call for investigations.
VA officials even confirmed with investigators that they simply don’t know what accounts for the decrease in investigations, prompting investigators to note that the National Center for Patient Safety, a part of the VA bureaucracy, “has limited awareness of what hospitals are doing to address the root causes of adverse events.”
Some safety officials, however, pointed to a perceptible shift in the culture of safety. According to these officials, employees seem less willing to report medical errors, despite the number of errors reported technically increasing. A 2014 survey of employees revealed that fewer believe they work in an environment in which they can draw attention to medical errors without being punished. This is an atmosphere highlighted by the litany of whistleblowers who have come forward over the last year testifying of retaliation after bringing to light safety issues and poor management. But instead of addressing the problem, many VA officials have elected to clamp down and gag whistleblowers.
This may mean that the errors reported are mostly minor, lending more credence to the explanation that trivial errors aren’t serious enough to warrant more investigations.
VA largely agreed with the conclusions of the report.
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