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On the heels of the report from the Institute of Medi cine (IOM), a report from the Depart ment of Veterans Affairs detailing a high error rate at VA hospitals has gained more attention than it might have otherwise. Some observers have suggested the VA report is typical of what might be required of all hospitals under the reporting requirements proposed in the IOM report.
Although the report was published July 15, 1999, it received no attention outside the VA until the IOM report was released at the end of 1999. The report documents nearly 2,927 medical mistakes in less than two years at VA hospitals around the country, including those leading to 710 patient deaths. The mistakes and deaths were recorded from June 1997 to December 1998 in the first 19 months of a new policy requiring VA employees to report medical errors and adverse events. The policy has resulted in about 200 reports per month, the report says.
The VA report concludes that the mandatory reporting policy is "a valuable and useful tool. It provides VHA additional data upon which to improve patient safety system-wide." The VA noted a number of ways to improve the data collection system, and the report calls for improved education of employees in how and what to report.
The VA medical system is the largest in the country, with 172 hospitals, 132 nursing homes, and more than 650 outpatient clinics.