The government’s chief watchdog has concluded that the Defense Health Agency (DHA) and military services need to devote more effort into compiling accurate tracking of serious adverse medical events. The respective military health agencies also should improve how they monitor required follow-ups to such incidents, the Government Accountability Office (GAO) stated in an April 26 report.
“Agency officials told us they spend 80 hours a month reconciling their records with the military services, but in some instances, the records don’t match,” GAO wrote. “The agency may be missing opportunities to make military health care safer.”
Under current procedure, each service’s medical treatment facilities plus that of the National Capital Region compile and track records. They then transmit them to the DHA by email. The agency, in turn, manually enters the information it gets into its tracking-record system.
The GAO report noted that the DHA does not have the capability to track “casual factors and corrective actions for sentinel events.”
The result is a disjointed tracking system that requires a time-consuming and inefficient reconciliation process, which can and does often result in wrong or missing information in DHA’s database. The agency has upgraded its system somewhat in recent years, but it still lacks the capability for individual services to enter it and make edits to wrong information.
“As a result, DHA lacks critical information about why a sentinel event may have occurred and what actions, if any, MTFs [military treatment facilities] should take to prevent similar incidents in the future,” GAO reported.
The report also expressed concerns about the different ways each service provides measures of success. As a result, DHA may not be getting all the information it needs to help develop a plan to implement broad, system-wide safety enhancements.
GAO recommends that DHA improve the tracking of sentinel reports, and clarify requirements for submitting these reports so that they are consistent and more readily usable for implementing changes that enhance patient safety.
