1.) 2.) 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. 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. 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. Policy on reviewing adverse medical events. 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. 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. 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. 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. 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. Without this information, DHA may be unable to identify  which MOS reports are missing. Specifically, the military services and NCR have been tracking the  submission of their MOS reports in different ways or not at all. DHA  officials told us that MTFs could meet this requirement by submitting  copies of their MOS reports. 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. 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. 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. Sentinel Event and Root Cause Analysis (SERCA) tool. 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. 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. 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.
Why GAO Did This Study

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.

What GAO Found

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.

What GAO Recommends

GAO recommends that the Assistant Secretary of Defense (Health Affairs) ensure DHA (1) improve tracking of sentinel events and RCA reports, and (2) clarify its requirements for submitting reports on the implementation of corrective actions and consistently track and reconcile individual reports. DOD agreed with these recommendations.