The bureaucratic train wreck that is the Department of Veterans Affairs is apparently producing more medical errors and fewer investigations into why such errors are occurring.

The Government Accountability Office (GAO) has issued a report saying the number of reported medical errors (or “adverse events”) at VA hospitals went up 7% from 2010 to 2014. During that same period, the VA system that cares for nearly 6 million veterans saw 14% more patients but spent less time finding out the cause of medical errors.

The GAO said investigations of adverse events dropped 18% from 2010 to 2014. Auditors were unable to determine why the VA was conducting fewer investigations. What’s worse is the VA doesn’t know why, either.

“It is unclear whether the 18 percent decrease in total [root cause analysis, or RCAs] completed from fiscal year 2010 to fiscal year 2014 is a negative trend reflecting less reporting of serious adverse events, or a positive trend reflecting fewer serious adverse events that would require an RCA,” according to the report.

VA officials told auditors that they haven’t looked into the decline or even whether hospitals are turning to another system, according to Lisa Rein of The Washington Post.

Inside the Veterans Health Administration is the National Center for Patient Safety, which is supposed to monitor investigations of medical errors. But, according to the GAO report, the center “has limited awareness of what hospitals are doing to address the root causes of adverse events.”

-Noel Brinkerhoff

To Learn More:

Medical Errors Are Up at VA Hospitals, But They’re Actually Doing Less to Figure Out Why (by Lisa Rein, Washington Post)

Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events (Government Accountability Office)

Hospitals Make Bigger Profit when Surgeries Go Badly than When they Go Smoothly (by Noel Brinkerhoff, AllGov)