News from AHRQ Patient Safety Network
Interim report by the VA Office of the Inspector General describes serious problems with access to care and documentation in the VA system.
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Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
The Veterans Health Administration has earned widespread praise for improving quality of care during the past decade, but this report by the Veterans Affairs (VA) Office of the Inspector General exposes serious problems within the Phoenix VA facility, which may be representative of system-wide issues with access to care. Even though the facility officially reported average wait times of only 24 days, the investigation found that veterans typically waited nearly 4 months for a new primary care appointment. This discrepancy was due to systematic manipulation of the scheduling system—more than 1700 patients had requested an appointment but were never enrolled on the waiting list for scheduling. Because wait times for primary care appointments were a VA quality metric, clinics likely resorted to gaming the system to appear to achieve their targets. The report indicates that evidence of inappropriate manipulation of the scheduling process has been found at many other VA facilities as well. The study did not formally address whether these delays in care directly led to deaths or preventable harm. An investigation of specific cases of deaths among patients who were waiting for appointments is ongoing and is expected to be released later this year.
Building physician work hour regulations from first principles and best evidence.
Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.
Use of electronic health records in US hospitals.
Jha AK, Desroches CM, Campbell EG, et al. N Engl J Med. 2009;360:1628-1638.
BOOK/REPORTView all related resources...
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
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