text: Background Adverse Medical Events DHA requires the military services and NCR to categorize adverse medical events by severity, using seven categories defined by the Agency for Healthcare Research and Quality (AHRQ), ranging from unsafe condition to death. (See table 1.) MTF personnel must enter all adverse medical events in DHA’s JPSR system, which was implemented in June 2011 in response to a statutory mandate for the MHS to establish a patient care error reporting and management system. The JPSR system is intended to provide ways to facilitate the self-reporting, collection, and aggregation of adverse medical event data across the MHS. The system includes prompts for information about factors that may have contributed to the event, such as medication or equipment, as well as the assignment of a severity category. From 2013 through 2016, the total number of reported adverse medical events in the JPSR system increased from over 76,000 to about 108,000. When analyzing adverse medical events, DHA groups the data into three categories—near miss, no harm, and harm. The highest increase was in the near miss category (about 36,000 to 56,000) while the other two categories increased to a lesser extent. According to an internal DHA publication, a higher increase in near miss events alongside a decrease in harm and no harm events is considered a positive trend because it shows that more potential adverse medical events are being detected before they reach the patient. (See fig. 1.) Sentinel Events The most severe types of adverse events are called sentinel events. In March 2015, DOD issued a memo that revised its previous definition of a sentinel event, which was an unexpected occurrence involving death or serious physical or psychological injury or risk. The revised definition states that a sentinel event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that results in death, permanent harm, or severe temporary harm. The revised definition also added a list of events outlined by the Joint Commission and the National Quality Forum that go beyond those that result in unexpected death or serious physical or psychological harm to the patient. (See app. I for the revised definition of sentinel events.) From 2013 through 2016, DHA’s data showed an increase in the total number of reported sentinel events—both medical and dental—from 121 to 319. Medical sentinel events approximately doubled from 101 to 206, while dental sentinel events increased more than fivefold from 20 to 113. (See fig. 2.) 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. A DHA internal publication also noted that a culture shift in patient safety reporting could have contributed to this increase. As with all adverse medical events, MTF personnel must enter sentinel events into the JPSR system; however, sentinel events have additional reporting requirements that must be met within specified time frames. For example, DHA policy requires MTF officials to report sentinel events to their respective military service or NCR within 24 hours after they become aware of the event. (See fig. 3, step 1.) MTFs also must report to and comply with sentinel event reporting requirements established by the Joint Commission. These requirements include the development and submission of an RCA report for each sentinel event to identify the causal and contributory factors associated with the event as well as the corrective actions needed to prevent future incidents. The military services and NCR submit copies of their RCA reports to DHA, which rates the corrective actions included in each RCA report as stronger, intermediate, or weaker based on an estimation of their effectiveness. (See fig. 3, step 2.) DHA uses commercial process improvement software called TapRooT to assist with the development of RCA reports, and DHA requires all MTFs to use a methodology for its RCA reports that is currently supported by this software. Additionally, once the Joint Commission approves an RCA report and its associated corrective action plan, it may require the preparation of an MOS report that assesses the corrective actions 4 months after an RCA report is submitted to determine whether the implementation of corrective actions and outcome measures was successful. Unlike RCA reports, these reports are only required for selected sentinel events as determined by the Joint Commission. DOD’s March 2015 memo that revised the definition of sentinel events contained an additional requirement for the military services and NCR to submit copies of reports on the implementation of corrective actions to DHA. (See fig. 3, step 3.) DHA officials told us that MTFs could submit their MOS reports to meet this requirement. For this report we use the term MOS report when referring to this requirement. Transition of MTF Administrative Responsibilities to DHA Responsibility for the delivery of care in the MHS is shared among the Office of the Assistant Secretary of Defense (Health Affairs), DHA, the military service medical commands, and NCR’s medical directorate. MTFs are currently under the direction and control of the Army Medical Command, the Navy Bureau of Medicine and Surgery, and the Air Force Major Commands. MTFs within the NCR are under the direction and control of the NCR medical directorate, which reports to DHA. (See fig. 4.) The NDAA 2017 included a provision that requires the Director of DHA to be responsible for the administration of every MTF beginning October 1, 2018. This responsibility includes budgetary matters, patient safety activities, information technology, and health care administration and management, among other things. As part of the patient safety activities, DHA officials will assume responsibility for adverse medical event reporting. As required, DHA submitted initial plans to Congress in both March and June 2017 about how it plans to implement its new responsibilities. In September 2017, we reported that DHA’s plans summarize its new roles and responsibilities at a high level and that a significant amount of work remained to complete the implementation plan. On March 30, 2018, DOD submitted an additional implementation plan and stated that its final implementation plan will be completed by June 30, 2018. The Military Services’ and NCR’s Adverse Medical Event Policies Do Not Consistently Align with DOD’s Policies, but Transition to DHA’s Policies Is Planned Policies established by the military services and NCR for reporting adverse medical events are developed to implement DOD’s policies— which tend to be broad—and may include additional requirements specific to their branch of military service. However, we found that aspects of these policies do not consistently align with DOD’s policies, including the definitions for adverse medical events and sentinel events, as well as requirements for entering events into the JPSR system. (See table 2.) Definition of adverse medical event. The Navy uses DOD’s definition of an adverse medical event—which includes events that may or may not result in harm to the patient. However, the Army, Air Force, and NCR defined this term more narrowly, to include only an event that causes actual harm to the patient. While the difference in these definitions could potentially result in the underreporting of events, officials from all four of the MTFs we visited told us that the discrepancy does not have much of an impact because the individuals who report these events—MTF personnel—are unlikely to be aware of the difference and likely follow the broader DOD definition. Policy on entering events in the JPSR system. Only NCR’s policy states that adverse medical events should be entered into the JPSR system. However, Army, Navy, and Air Force officials as well as officials from one MTF we spoke with stated that they record all adverse medical events in the JPSR system even though their policies do not require it. Policy on reviewing adverse medical events. NCR and Air Force policies, which align with DOD’s policy, require a review of an adverse event that is based on whether there is harm to the patient. In contrast, Army and Navy policies do not require that an adverse medical event be reviewed on the basis of whether there is harm to the patient, but they do require the event to be reviewed for the level of severity and probability of recurrence. However, Navy officials told us that reviewing an event for severity includes an assessment of harm to the patient even though this is not clearly stated in their policy. Additionally, all of the MTF officials we interviewed said that the JPSR system requires them to review an adverse medical event on the basis of whether there is harm to the patient and to assign a harm scale category. Memorandum that revised the definition of a sentinel event. Only the Army’s draft policy aligned with DOD’s March 2015 revised definition of sentinel events. However, MTF officials from the other military services and NCR told us that even though the revised definition was not in their policies, they were aware of the memo and were using this definition. Memorandum that requires the military services and NCR to submit copies of their reports on the implementation of corrective actions to DHA. The Army’s draft policy that aligned with DOD’s revised definition of sentinel events also included a section requiring the submission of these reports to DHA. The policies of the other military services and NCR do not include this requirement. However, officials from the other military services we interviewed told us that they are aware of this requirement and are submitting MOS reports to meet this requirement. NCR officials told us that they are aware of this requirement but have not begun submitting these reports. In March 2017, DOD’s senior military medical leadership published operating principles to guide the implementation of specific MHS requirements outlined in the NDAA 2017. One of the operating principles to guide the transition of MTF administrative responsibilities to DHA requires DHA to create all health care policies for the direct care system (the MTFs) to ensure greater consistency and eliminate duplicative governance. As a result, the military services and NCR will no longer be establishing their own policies. According to DHA officials, the transition for DHA to be the single policy writer for MTFs will take time, and policies issued by the military services and NCR will remain in place until they are superseded by revised DHA policies. DHA officials are in the process of updating the department’s patient safety policy through the Patient Safety Improvement Collaborative, a working group that includes patient safety representatives from all of the military services, NCR, and DHA. However, as of January 2018, DHA officials were uncertain as to when this effort would be complete. Fragmented Process for Tracking Sentinel Events and RCA Reports Impedes DHA’s Ability to Ensure It Has Received Complete Information Process Used by the Military Services, NCR, and DHA to Track Sentinel Events and RCA Reports Is Fragmented Sentinel Event Tracking We found that the process used by the military services, NCR, and DHA to track sentinel events is fragmented. (See fig. 5.) Similar to all other types of adverse events, DHA requires that sentinel events be recorded in the JPSR system. However, DHA officials told us there are additional follow-up reports and associated deadlines for sentinel events that go beyond the JPSR system’s current tracking capabilities, and as a result, officials from each of the military services and NCR told us they track sentinel events in their own tracking record outside of the JPSR system. Officials told us the military services and NCR receive reports about sentinel events from their MTFs via email, which are then entered in their respective internal tracking records and reported to DHA via email. DHA then enters and tracks the sentinel events in its own internal tracking record. DHA officials told us that they do not believe that all sentinel events are being entered in the JPSR system, and that the JPSR system does not currently have the capability to pull sentinel event data for tracking purposes. As a result, the same sentinel events are entered and tracked in two separate tracking records—DHA’s tracking record and the tracking records maintained by the military services or NCR. In a similarly fragmented process, MTFs email RCA reports—a requirement for sentinel events—separately to their respective military services or NCR, which then emails them to DHA. Although DHA requires MTFs to use a methodology currently supported by the TapRooT system to complete their RCA reports, DHA officials told us the TapRooT software is not compatible with most MTFs’ computer systems, and as a result, MTFs do not share RCA reports through this system. Instead, they told us MTFs use the methodology from the TapRooT system to prepare the RCA report as a standalone document. Officials told us MTFs then email the RCA reports to their military service or NCR, which notates the RCAs in their respective internal tracking record. The military services and NCR email the RCA reports to DHA, which notates the reports in its own internal tracking record. Fragmented Tracking Impedes DHA’s Ability to Ensure That It Has Complete Information on Sentinel Events and RCA Reports Because the process used by the military services, NCR, and DHA to track sentinel events and RCA reports is fragmented, DHA officials told us they must rely on their reconciliation process to ensure they have complete information. Specifically, on a monthly basis, DHA officials email separate spreadsheets of DHA’s sentinel event records to each of the military services and NCR requesting confirmation of reported sentinel events and the status of overdue RCA reports, among other 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. 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. The cooperation of the military services and NCR is key to this process because officials told us that DHA currently has no authority to compel a response from these entities, although this may change with the transition of MTF administrative responsibilities to DHA. DHA officials told us they sometimes do not receive a response to their emails, and in these cases, DHA assumes concurrence. In an effort to improve the reconciliation process and compliance with RCA report submission requirements, DHA officials told us that they developed a new tool called the Comprehensive Analysis Progress Tracker for all three military services and NCR. DHA officials told us this tracker shows the full cycle of each sentinel event, including which RCAs are overdue, and is available on the MHS internal website. DHA officials told us that this tracker, launched in October 2017, replaced the previous system of separate monthly reconciliation emails with individual spreadsheets for each military service and NCR. In January 2018, DHA officials told us they began using this tracker at monthly Patient Safety Improvement Collaborative meetings and will use it during monthly check-ins with the military services and NCR to discuss delayed or missing items. However, the military services and NCR cannot directly edit the Comprehensive Analysis Progress Tracker. As a result, DHA officials told us that the military services and NCR will continue to use email to submit their sentinel events and RCA reports as well as any corrections or additional information needed for the tracker, which may perpetuate previous inefficiencies. Despite Reconciliation Efforts, DHA Does Not Have Complete Information on Sentinel Events and RCA Reports Despite DHA’s efforts to reconcile its information on sentinel events and RCA reports, we identified discrepancies and missing information in its tracking record. Sentinel Event Discrepancies We found that the sentinel events in all of the military service and NCR tracking records matched DHA’s tracking record except for those of the Navy. Specifically, DHA had a record of 19 sentinel events that the Navy did not have for 2013 through 2016. DHA officials were not sure of the reason for the discrepancy between their tracking record and the Navy’s, but told us that sometimes sentinel events are reported to DHA and later determined to not be reportable, and DHA is not given the updated status of the event. Navy officials told us that although they initially reported these 19 events as sentinel, the Joint Commission informed the Navy that it did not consider these events to be sentinel after reviewing the Navy’s submission. Navy officials told us that they determined these events also did not meet other sentinel event criteria per DHA’s revised definition, which goes beyond the definition used by the Joint Commission. Further, Navy officials told us they informed DHA that these events had been deemed non-sentinel by the Joint Commission, and DHA’s tracking record subsequently noted this. However, DHA did not remove the events from its tracking record. RCA Report Discrepancies We found discrepancies in the number of RCA reports when comparing DHA’s internal tracking record to the military services’ and NCR’s internal tracking records. 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: DHA had more RCA reports in its internal tracker than in the Army’s internal tracker for 2015 (2 more) and 2016 (1 more). DHA had fewer RCA reports than the Air Force in 2013 (3 less), 2014 (2 less), 2015 (13 less), and 2016 (1 less). Additionally, DHA had fewer RCA reports for reported sentinel events for NCR in 2015 (1 less) and 2016 (18 less). Officials with the military services and NCR told us they did not know why there were differences between their tracking records and those of DHA. However, Army and NCR officials offered potential reasons for these differences. Army officials told us that they may have fewer RCA reports than DHA because they recently transitioned their sentinel event and RCA tracking record from a spreadsheet format to a database, and some reports may not have been copied into the database. NCR officials told us their tracking record may not match DHA’s tracking record because an MTF may submit only one RCA report to DHA that covers multiple similar sentinel events, so DHA may have fewer reports documented in its internal tracking record. Missing RCA Reports For some reported sentinel events, we found that the required RCA reports had not been recorded in any tracking record for the Army, NCR, or DHA. (See table 3.) Army and NCR officials told us that they did not know why they did not have a record of an RCA report for every sentinel event in their internal tracking record. However, these officials explained that there are a number of potential reasons that RCA reports could be missing, including insufficient MTF staff to carry out these activities, and MTF officials’ confusion about the revised definition of a sentinel event. DHA officials told us that they did not know the reasons for the discrepancies between the tracking records for the military services, NCR, and DHA or for the missing RCA reports. Specifically, DHA officials did not know whether these reports were completed but not submitted to DHA or were not completed at all. They told us that they rely on the cooperation of the military services and NCR to submit these reports and cannot enforce the requirement, although this may change with the transition of MTF administrative responsibilities to DHA. Because of these discrepancies and missing RCA reports, DHA lacks critical information about why a sentinel event may have occurred and what actions, if any, MTFs should take to prevent similar incidents in the future. We have previously reported that when fragmentation or overlap exists, there may be opportunities to increase efficiency. In particular, our prior work identified management approaches that may improve efficiency and effectiveness, including implementing process improvement methods and technology improvements. As MTF patient safety responsibilities are transitioned to DHA, the fragmented tracking process may hamper DHA’s ability to efficiently and effectively monitor sentinel events and RCA reports, potentially leading to missed opportunities for systemic improvements. DHA’s Efforts to Ensure It Receives MOS Reports Are Limited and Impeded by Inconsistent Report Tracking and Unclear Requirements about Report Submission DHA’s Efforts to Ensure It Receives MOS Reports Are Limited and Impeded by Inconsistent Report Tracking As of September 2017, DHA had received 27 MOS reports for the 319 sentinel events that were reported in 2016. However, DHA does not know how many reports it is missing because its efforts to reconcile information for these reports have been limited. Prior to January 2018, DHA did not include MOS reports as part of its reconciliation process for sentinel events and RCA reports. However, in January 2018, DHA officials told us they added MOS reports to their new monthly reconciliation process using the Comprehensive Analysis Progress Tracker. While this tracker displays the total number of MOS reports DHA has received, it does not display whether individual reported sentinel events have an associated MOS report. Without this information, DHA may be unable to identify which MOS reports are missing. DHA officials told us that they may revise the Comprehensive Analysis Progress Tracker to follow up on MOS reports associated with specific sentinel events in the future. DHA’s efforts to identify which MOS reports are missing are further impeded by the military services’ and NCR’s inconsistent tracking efforts. Specifically, the military services and NCR have been tracking the submission of their MOS reports in different ways or not at all. Army officials had told us that the completion of MOS reports was noted in their internal tracking record for sentinel events and RCAs. Army officials subsequently told us that as of January 2018, they began tracking whether MOS reports were submitted to DHA in the notes section of their internal tracking record. Navy officials told us they indicated the due date of the MOS report and the date of its submission to DHA in their internal tracking record for sentinel events and RCA reports. Air Force officials told us they indicated in their internal tracking record for sentinel events and RCA reports the date that the MOS report was sent to DHA. However, they told us the Air Force’s process for tracking and submitting MOS reports to DHA has been inconsistent, and they plan to revise it in the future. NCR officials told us they did not track the completion of MOS reports or their submission to DHA. Because of these issues, DHA may not be able to fully reconcile its information for individual MOS reports or identify the reports it is missing, impeding its ability to obtain complete information on the effectiveness of MTFs’ corrective action plans. This is inconsistent with federal internal control standards, which require management to identify and respond to risks to achieve its objectives, and for management to use quality information to achieve its objectives. DOD’s Requirement to Submit Reports on the Implementation of Corrective Actions Is Unclear The requirement in DOD’s memo to submit reports on the implementation of corrective actions is unclear, which may also impact DHA’s ability to ensure that it is receiving these reports for all sentinel events. DHA officials told us that MTFs could meet this requirement by submitting copies of their MOS reports. According to the Joint Commission’s guidance, the Joint Commission assigns MOS reports on an ad hoc basis, depending on the sentinel event, RCA report, and corrective actions, and as a result, an MOS report is not necessarily required for each sentinel event. DHA officials told us that they intended to obtain a report on the implementation of corrective actions for every sentinel event, and they believed that an MOS report was required and thus would be reported for every sentinel event, similar to RCAs. However, DHA officials told us that they learned from the military services and NCR at the January 2018 Patient Safety Improvement Collaborative meeting that an MOS report was not required for every sentinel event and that DHA’s requirement for submitting reports on the implementation of corrective actions was unclear. Specifically, DHA officials told us the military services and NCR told DHA that the 2015 memo did not state when the reports on the implementation of corrective actions are required by DHA. For example, the memo did not state whether DHA requires this report for a reported sentinel event and RCA when the Joint Commission does not. DHA’s unclear requirement is inconsistent with internal control standards, which require management to review policies for continued relevance and effectiveness in achieving the entity’s objectives. Under the current policy, DHA cannot be sure it is receiving all reports on the implementation of corrective actions—such as MOS reports—as it intended, and therefore, it may be missing important information on the effectiveness of MTFs’ implementation of their corrective actions that could be used to help inform broader system-wide improvements. DHA officials told us that they expect to clarify this requirement in DHA’s update to its patient safety policy. DHA Uses Information about Adverse Medical Events to Inform System-wide Patient Safety Improvement Initiatives We found that DHA has introduced several system-wide patient safety improvement initiatives informed by data on adverse medical events from the JPSR system and data on sentinel events from DHA’s tracking database, including the following: DHA’s Partnership for Improvement. In January 2015, DHA established an MHS-wide information technology system called the Partnership for Improvement. The Partnership for Improvement collects data from MTFs and assesses MTF performance on approximately 38 health care measures that were established by a committee of MHS officials and designed to improve readiness, population health, and quality of care as well as control costs. Three of these measures focus on patient safety—central line-associated bloodstream infection, unintended retained foreign object, and wrong site surgery. To track these measures, DHA officials told us that they created an associated performance dashboard, including acceptable ranges for each measure, to provide visibility into MHS, military service-, and NCR-level performance. The dashboard is available to all MHS users on the system website and allows MTF leaders and staff to review MTF-level performance data. DHA officials conduct quarterly system-wide performance assessments on these measures. DHA officials told us they use the data on this dashboard to determine what is improving and where to make changes. Officials from each of the military services, NCR, and each of the MTFs we visited told us they are aware of the Partnership for Improvement and its associated dashboard and that they review the data to assess their performance. Publications on Patient Safety. DHA produces several types of publications using adverse medical event and sentinel event data that officials told us are generally distributed to MTFs through the military services and NCR, including the following. Patient Safety Data Snapshot. This monthly publication contains an overview of adverse medical event and sentinel event data, trends across the MHS, and short descriptions of sentinel events that have been reported in the system in the same month. Additionally, this publication may include reports of medical product deficiencies, or materials that have been determined to be or are suspected of being harmful, defective, deteriorated, or unsatisfactory because of malfunction or design. Annual patient safety report. This yearly publication provides a retrospective status update on MHS patient safety initiatives and in- depth adverse event and sentinel event trend analysis, system-wide and by military service. Content includes trends in adverse events reported in JPSR, sentinel events, and RCAs, including information on weaker, intermediate, and stronger corrective actions. This report also describes progress on Partnership for Improvement measures system-wide and by military service and NCR, the culture of patient safety, and collaboration across DHA, the military services, and NCR. The report also details online resources for MHS officials. Focused review. According to officials, focused review publications are produced three times a year, and the topics are related to adverse medical events and associated follow-up data provided to DHA as determined by data and performance trends. For example, in September 2016, the publication included an explanation of the basic components of an RCA, including their associated corrective actions and factors DHA considers when determining if they are stronger, intermediate, or weaker. This publication included 2013 through 2016 system-wide data, such as the number of RCAs submitted, the most common root cause categories, and the proportion of RCAs with stronger, weaker, or no corrective actions. The publication also included an example of a decrease in occurrences of wrong-site surgery accompanied by an improvement in RCAs with stronger corrective actions, common pitfalls in conducting high-quality RCAs, and recommendations to conduct better RCAs. Patient safety alerts. DHA uses these publications to inform the MHS about immediate hazards, and officials told us they produce these publications on an as-needed basis. For example, a July 2016 report was focused on unintended retained foreign objects during surgery, specifically, pieces of gloves. The publication described recent occurrences of retained pieces of gloves, glove selection best practices, tips for preventing unintended retention, and corrective actions when retention occurs. Global Trigger Tool. The Global Trigger Tool is a new tool for collecting adverse medical event data by selecting a sample of medical charts that was implemented MHS-wide as of September 2017. Unlike traditional methods to detect adverse events, the Global Trigger Tool does not focus on voluntary reporting and tracking of adverse medical events. Instead, a team of three reviewers managed by DHA uses the tool methodology to retrospectively examine a random selection of patient medical charts at a facility over time to identify “triggers” (or clues) that may lead to an adverse medical event. The 53 triggers include events such as a patient fall or readmission to the emergency department within 48 hours of treatment. If a trigger is discovered, the medical chart is further reviewed to determine if an adverse event occurred. After the Global Trigger Tool review is complete, the contractor is able to provide facility leaders with rates of harmful adverse events per 1,000 patient days and per 100 admissions. Results from the tool are intended to aid MTFs in understanding the true frequency of harm events and in identifying systemic issues that contribute to patient safety events. All inpatient MTFs across the MHS will use the tool, and implementation began in 2017. The Global Trigger Tool has just begun to provide data to the MTFs, and DHA officials told us that 6 to 12 months of data is recommended before the tool can be used to make improvements. Sentinel Event and Root Cause Analysis (SERCA) tool. In October 2017, DHA released a dashboard called the SERCA tool, which DHA officials told us will allow all MTF patient safety leaders to share lessons learned in the course of sentinel event follow-up in real time. The SERCA tool displays sentinel event and RCA data from DHA’s internal tracking record reported by the military services and NCR. It is intended to provide quick, online access to sentinel event trends MHS-wide and at the military service, NCR, and MTF levels. The SERCA tool is also intended to facilitate sharing of lessons learned and best practices based on sentinel events and RCAs in a single platform. DHA officials told us that individuals with access to the system will be able to see a breakdown of corrective actions submitted by other MTFs for a particular type of sentinel event and whether these corrective actions were rated as stronger, intermediate, or weaker by DHA. DHA officials told us that for now, they will allow the military services and NCR to determine who has access to the system. Officials from two military services and NCR told us that they have access to this tool and are responsible for granting access to their MTFs. One MTF we visited told us they have access to this tool. However, it is too early to evaluate how the SERCA tool will be used to make improvements. Conclusions Each year, thousands of adverse medical events are reported at MTFs. Tracking and conducting follow-up on these events is crucial for officials to learn from and prevent these events in the future. As DHA assumes administrative responsibility for all MTFs, its role in ensuring that sentinel events—the most serious type of adverse medical events—are reported and tracked and that required follow-up is conducted will become increasingly critical. However, the current fragmented and inconsistent tracking process across the military services and NCR has impeded the efficiency of DHA’s efforts to ensure DHA has complete information about sentinel events and RCA reports. Furthermore, DHA cannot ensure that it is receiving all reports on the implementation of corrective actions, such as 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. 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. This information is essential to prevent adverse medical events from occurring in the future and to ensure that the care provided by MTFs is safe and effective. Recommendations for Executive Action We are making the following two recommendations to the Assistant Secretary of Defense (Health Affairs): Ensure DHA improves as appropriate the systems and processes used by the military services, NCR, and DHA to track sentinel events and RCA reports and require the military services and NCR to communicate with DHA the reasons RCA reports are not completed for reported sentinel events. (Recommendation 1) Ensure DHA clarifies its requirement that reports on the implementation of corrective actions, such as MOS reports, should be completed and submitted to DHA, and to work with the military services and NCR to develop a standard system to help DHA consistently track and reconcile information about individual reports. (Recommendation 2) Agency Comments DOD provided written comments on a draft of this report, including technical comments, which we incorporated as appropriate. In its written comments, which are reprinted in appendix II, DOD concurred with both of our recommendations. In response to our first recommendation, DOD acknowledged that its current tracking efforts for sentinel events and RCAs are fragmented, inefficient, and unreliable. DOD stated that in the future, it envisions a single system to track and monitor sentinel events, RCAs, and corrective action implementation plan reports. A single system would eliminate the fragmentation associated with tracking these reports and the need for a cumbersome reconciliation process, potentially improving the completeness and reliability of DHA’s patient safety data as well as its ability to identify and implement system-wide improvements. In response to our second recommendation, DOD stated that it will clarify the difference between an MOS report, which may be required by the Joint Commission, and a corrective action implementation plan report, which will always be required by DOD for reported sentinel events. DOD explained that when an MOS report is required by the Joint Commission, this report will satisfy DOD’s requirement. However, when the Joint Commission does not require an MOS report for a sentinel event, DOD will require a corrective action implementation plan report. DOD stated that it expects the revised policy to be signed in late summer 2018 and in effect by October 1, 2018—the date that DHA is to assume responsibility for the administration of all MTFs. We are sending copies of this report to the Secretary of Defense and appropriate congressional committees. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or at draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix III. Appendix I: Department of Defense’s (DOD) Revised Definition of a Sentinel Event In a March 2015, the Assistant Secretary of Defense for Health Affairs issued a memorandum about improving the sentinel event and root cause analysis (RCA) reporting processes. This memorandum also revised DOD’s definition of sentinel events, which previously stated that a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or risk. The revised sentinel event definition is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm. This revised definition also includes additional types of events outlined by the Joint Commission and the National Quality Forum. (See table 4.) DOD described the following sentinel events that are outlined by the Joint Commission: Suicide of any patient receiving care, treatment, and services in a staffed around-the clock care setting or within 72 hours of discharge, including from the hospital’s emergency department. Unanticipated death of a full-term infant or discharge of an infant to the wrong family. Abduction of any patient receiving care, treatment, and services. Any elopement (unauthorized departure) of a patient from a staffed around-the-clock care setting (including the emergency department), leading to death, permanent harm, or severe temporary harm to the patient. Destruction of red blood cells transfusion reaction involving administration of blood or blood products that have major blood group incompatibilities. Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care, treatment, and services while on site at the hospital. Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure. Unintended retention of a foreign object in a patient after an invasive procedure. Severe neonatal excess of bilirubin (bilirubin >30 milligrams/deciliter). Prolonged fluoroscopy with cumulative dose >1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25 percent above the planned radiotherapy dose. Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care. Any maternal death or severe maternal or morbidity occurring during or after birth (24 hours). Appendix II: Comments from the Department of Defense Appendix III: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to those named above, key contributors to this report were: Bonnie Anderson, Assistant Director; Danielle Bernstein, Analyst-in- charge; Jacquelyn Hamilton; Elizabeth T. Morrison; Vikki Porter; and Helen Sauer.
target: Adverse medical events are unintended incidents that may harm a patient. Serious adverse medical events, called sentinel events, have specific follow-up requirements. The National Defense Authorization Act for Fiscal Year 2017 (NDAA 2017) requires DHA to assume the military services' administrative responsibilities, such as adverse medical event reporting, for all MTFs beginning October 1, 2018. The NDAA 2017 included a provision for GAO to examine the reporting and resolving of adverse medical events in the military health system. Among other objectives, this report reviews (1) the extent to which sentinel events and RCA reports are tracked and DHA ensures it has received complete information, and (2) the extent to which DHA ensures it has received MOS reports. GAO examined relevant policies; analyzed the most current available data on sentinel events from 2013 through 2016; and interviewed officials with DHA, the military services, and four MTFs selected for variety in military service, size, and geographic location. GAO found that the process for tracking the most serious adverse medical events, called sentinel events, and their root cause analysis (RCA) reports are fragmented, impeding the Defense Health Agency's (DHA) ability to ensure that it has received complete information. Unlike other adverse medical events, sentinel events—which may result in severe harm or death—have additional reporting requirements that must be met within specified time frames. For example, military treatment facility (MTF) officials must develop RCA reports, which identify causal factors and corrective actions for sentinel events. However, because the database that DHA uses to collect information on adverse medical events does not currently have the capability to track this information, the military services (Army, Navy, and Air Force) and DHA each maintain their own tracking records for sentinel events and RCA reports. Due to these fragmented tracking efforts, DHA reconciles its information on sentinel events and RCA reports through monthly emails to the military services—a time-consuming, inefficient process. DHA officials emphasized that this process relies on the military services' cooperation because DHA does not currently have the authority to compel their responses. Moreover, despite DHA's reconciliation efforts, GAO identified discrepancies and missing information in DHA's tracking record. As a result, DHA lacks critical information about why a sentinel event may have occurred and what actions, if any, MTFs should take to prevent similar incidents in the future. Recently, DHA replaced its previous system of emails with a new tracker tool that can be accessed on the military health system website. However, the new tracker does not allow the military services to make edits, and as a result, any corrections or additional information must be submitted to DHA via email, which may perpetuate previous inefficiencies. GAO found that DHA cannot ensure that it is receiving all reports on the implementation of corrective actions identified in RCA reports as required by a March 2015 memo. DHA officials stated that MTFs could meet this requirement by submitting copies of their measures of success (MOS) reports, which may be required by the Joint Commission, a hospital accrediting organization. As of September 2017, DHA had received 27 MOS reports for the 319 sentinel events that were reported in 2016. However, DHA does not know how many reports it is missing because MOS reports are not required for every sentinel event, and DHA did not began reconciling its information for these reports until January 2018, when it implemented its new tracker tool. Furthermore, GAO found that the new tracker tool documents the aggregate number of MOS reports received and does not indicate whether individual sentinel events have an MOS report, impeding DHA's ability to identify which reports are missing. This issue is compounded by the fact that the military services either track MOS reports in different ways or not at all, and military service officials said that DHA's requirement for MOS report submission is not clear. DHA officials stated that they expect to clarify this requirement in their update to the patient safety policy. Because it is unable to ensure it has received all reports on the implementation of corrective actions, DHA could be missing important information that could be used to help inform broader, system-wide patient safety improvement efforts.