“One of the key patient safety responsibilities within the Department of Defense’s (DOD) Military Health System (MHS) is the reporting and tracking of adverse medical events—unintended health care incidents, such as administering incorrect medication or treatment to a patient, that may or may not result in harm…”
“The military services (Army, Navy, and Air Force) and the National Capital Region (NCR) currently manage their own hospitals and clinics, referred to as military treatment facilities (MTF). In doing so, they develop policies that must align with DOD’s policies, including policies for reporting adverse medical events that occur in their facilities.2 However, the National Defense Authorization Act for Fiscal Year 2017 (NDAA 2017) requires the transfer of administrative control of MTFs, including the reporting of adverse medical events, to DHA, beginning October 1, 2018…”
“To examine the extent to which the military services and NCR have policies that align with DHA’s policies for reporting adverse medical events, we reviewed and compared the military services’ and NCR’s policies with DHA’s policies. We also reviewed relevant documents related to these policies, including updated memorandums…”
“GAO found that the process for tracking the most serious adverse medical events, called sentinel events, and their root cause analysis (RCA) reports are fragmented…”
“GAO recommends that the Assistant Secretary of Defense (Health Affairs) ensure DHA (1) improve tracking of sentinel events and RCA reports, and (2) clarify its requirements for submitting report…” Read the full report here.
Source: Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up – April 26, 2018. GAO.gov.
