Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama

The VA Office of Inspector General (OIG) reviewed concerns related to the Patient Safety Program at the Tuscaloosa VA Medical Center (facility) and programmatic oversight provided by facility and Veterans Integrated Service Network (VISN) 7 leaders. While conducting a separate healthcare inspection at the facility, the OIG received a Veterans Health Administration (VHA) Issue Brief identifying Patient Safety Management Program concerns, including the failure to complete approximately 160 reported patient safety incidents within the required 14 days. These concerns followed the extended leave and abrupt retirement of the former Patient Safety Manager (PSM). Additional failures included not completing the required patient safety root cause analyses and risk assessments, and the former PSM not attending meetings with facility and VISN committees. The OIG substantiated the concerns, which the former PSM attributed in part to lack of support, supervisory engagement, and resources, and identified other concerns with program oversight and the facility’s culture of safety. The facility had multiple pathways for oversight but missed opportunities to identify and mitigate gaps in the program. The OIG concluded that lack of action by facility leaders contributed to these missed opportunities. VA concurred with the OIG’s 11 recommendations, including four addressed to the Under Secretary for Health related to granting specific positions access to patient safety program databases, reporting state licensing board actions to supervisors, patient safety program oversight, and publishing updated and relevant policies. The VISN Director also agreed to review patient safety event reports and the role of the Patient Safety/Risk Management Subcommittee in overseeing facility-level Patient Safety activity performance. The Facility Director concurred with recommendations for the timely completion and investigation of patient safety events, feedback to patient safety event reporters, reviews of events, and ensuring programmatic oversight and accountability, with documentation of discussion, review, and action.