The GAO pointed out that, as part of the patient safety activities, DHA officials will assume responsibility for adverse medical event reporting beginning Oct. “In some instances, we found that DHA had more RCA reports in its tracking record than the military services or NCR for reported sentinel events, and in other instances, DHA had fewer RCA reports in its tracking record than the military services or NCR,” the report stated.
The GAO also noted that it found “discrepancies” in the number of RCA reports when comparing DHA’s internal tracking record to the military services’ and internal tracking records from the National Capital Region (NCR). “Additionally, officials told us that sometimes information about sentinel events and RCA reports is lost or not effectively communicated due to complexities related to routing the email submissions and to turnover in the contract staff who track and reconcile this information.” “DHA officials acknowledged that their reconciliation process is inefficient and told us that their full-time employees and contractors spend an average of 80 hours per month working on it,” the review stated. The reports are then transmitted via email to DHA, where they are manually entered into a tracking record.īecause the process used to track sentinel events and RCA reports is fragmented, DHA officials said they rely on their reconciliation process to ensure they have complete information, according to the GAO report. As a result, MTFs create tracking records of sentinel events. Sentinel events require some additional reports that the JPSR does not have the capability of tracking, however. “Medical sentinel events approximately doubled from 101 to 206, while dental sentinel events increased more than fivefold from 20 to 113,” the report pointed out, suggesting, “The sharp increase in events in 2015 may have been influenced by DHA’s revised definition of sentinel events, as well as the Army’s inclusion of dental events that meet sentinel event criteria.”Ĭurrently, MTF staff enter adverse event information into DHA’s Joint Patient Safety Reporting system (JPSR). Prior to that, a sentinel event was considered to be an unexpected occurrence involving death or serious physical or psychological injury or risk.įrom 2013 through 2016, DHA’s data showed an increase in the total number of reported medical and dental sentinel events from 121 to 319. In 2015, DoD redefined its definition of a sentinel event to be a patient safety issue that results in death, permanent harm or severe temporary harm. “Collectively, all of these information gaps impair DHA’s ability to fully understand the types of sentinel events that are occurring in its MTFs, the corrective actions that have been implemented, and whether these actions have been effective.” “DHA cannot ensure that it is receiving all reports on the implementation of corrective actions, such as Measures of Success (MOS) reports, and does not know how many reports it is missing for a number of reasons, including those related to policy, tracking, and reconciliation efforts,” GAO authors wrote.
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