Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

摘要

Through its policy and guidance, VHA has outlined processes that enable VAMCs to respond to reported adverse events that occur. VHA generally grants individual VAMCs discretion on choosing which process to use. Specifically, VAMCs conduct an initial review to determine how best to respond to an adverse event. According to VHA officials, if the circumstances that led to an adverse event are clear, based on a VAMC's initial review, VAMCs can take immediate corrective action. If the circumstances that led to an adverse event need to be examined further, VAMCs are given discretion to use one or more of the following four processes: (1) root cause analysis, (2) peer review, (3) clinical care review, and (4) administrative investigation board. Because VAMCs generally have discretion in which of these processes they use, different VAMCs that experience similar adverse events may not use the same processes to respond to them. Nonetheless, each process has certain purposes and limitations. For example, some of these processes may be used to examine a clinician's actions as they relate to an adverse event, while others may be used to examine whether a systems or process issue exists. Furthermore, information collected through two of these processes--clinical care reviews and administrative investigation boards--can be used to inform actions against clinicians; information collected using root cause analyses and peer reviews cannot be used to support such actions, because information collected under those processes is protected and confidential, under federal law. Based on the nature of an adverse event and the information gleaned through a particular review process, a VAMC may decide to conduct multiple types of reviews, as appropriate.