U S Government Accountability Office

VA health care U S Government Accountability Office

" Adverse events-clinical incidents that may pose the risk of injury to a patient as the result of a medical intervention, rather than the patient's underlying health condition-can occur in all health care delivery settings. VAMCs can use one or more of the protected (confidential and nonpunitive) and nonprotected processes to evaluate the role of individual providers in adverse events. GAO was asked to review the extent to which processes used to respond to adverse events are carried out across VAMCs. In this report, GAO examined (1) VAMCs' adherence to VHA's protected peer review process, and the extent to which VHA monitors this process, and (2) VAMCs' adherence to VHA's nonprotected processes and the extent to which VHA monitors these processes. To conduct this work, GAO visited four VAMCs selected for variation in size, complexity of surgeries typically performed, and location. GAO reviewed VHA policies and federal internal control standards and analyzed data from the four selected VAMCs. GAO also interviewed VHA and VA OIG officials, as well as officials from VISNs of the four selected VAMCs. "