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Thank you, Mr. Everett and Ms. Brown for holding this hearing today. The Office of the Medical Inspector (OMI) of the Department of Veterans Affairs (VA) has reported a total of 2,927 medical errors in a period of a year and a half, of which over 700 resulted in accidental patient deaths or suicides.

Nobody wants to hear that they or someone they care about has been the victim of a life-threatening mistake. No member of this committee will defend any number of avoidable patient deaths at VA.

VA is certainly not the only health care system that makes mistakes. The Institute of Medicine (IOM) says VA is simply reporting the types of problems other providers would be reporting if they were required to do so. A recent study looking at all health care estimated that as many as 20% of deaths are linked to mistakes in managing prescription drugs. Medical errors throughout the health care industry are more common than it wants to acknowledge.

The Department of Veterans Affairs is the first health care system to come forward publicly with its recorded mistakes, and it takes a lot of courage for VA to do so. VA understands that someone needs to set a standard for our health care system that encourages clinical staff to admit their mistakes so these errors can be corrected.

While there is much that can be done to reduce such deaths, no health care system can ever eliminate them entirely. But if VA doesn’t know what mistakes are made, and if staff feel they must hide them, our veterans hospitals will never know how to correct the problems that may lead to these tragic errors. The aviation industry has appreciated fact for a long time, and uses a "no-fault" reporting system VA is now installing. It takes pains to identify the causes of problems and take corrective actions to avoid problems reoccurring.

Most important, if the new systems work correctly, we will learn which mistakes are individual error and which ones are systemic. For example, VA has seen a significant number of problems with concentrated potassium chloride being given incorrectly in patient care units. While each such case was somebody’s mistake, VA concluded there was no good reason to have concentrated potassium chloride available in patient care units. Having it there was a systemic mistake discovered through statistics. This is a significant discovery that allowed VA to take action.

Though VA has launched its own study of these risks, a study of private and other non-VA health care has not yet been undertaken. What are the issues that will be critical as VA explores patient safety? These include:

• Which problems have simple solutions?
• Which problems does VA identify as the most serious?
• How does VA assign task groups to find solutions to these problems?
• How quickly and effectively does VA apply solutions?

• Do the numbers for these problems actually decrease once they are addressed?

Today’s witnesses will tell us what VA has learned to date, and what progress it has made in installing systems that may lead to identifying and minimizing medical misadventures. It is an important hearing, and there will be more in the future.

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