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Publication Briefs

Study Examines Patient Safety Issues in VA Outpatient Setting

A 2011 report from the American Medical Association concludes that "we still know very little about patient safety in the ambulatory setting, and next to nothing about how to improve it." VA's National Center for Patient Safety, which leads patient safety initiatives within the VA healthcare system, defines root cause analysis as "a process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or close calls." This retrospective study analyzed 111 root-cause analysis reports that investigated delays in the VA outpatient setting that were submitted to VA's National Center for Patient Safety from 2005 to 2012. Investigators examined delays within the context of four dimensions of ambulatory care processes: the provider-patient encounter (history gathering and other exchanges within a patient visit); performance and interpretation of diagnostic tests; follow-up and tracking of patients; and referral and consultation processes.


  • Based on root-cause analysis reports, most outpatient delays arose from multiple dimensions of ambulatory care processes and involved a large number of contributory factors.
  • Most contributory factors were related to communication and coordination among providers, non-providers (i.e., clerical and admin support staff), and patients. Failures in the process of follow-up and tracking of Veterans were especially prominent, mentioned in more than half of the reports.
  • The 111 reports examined in this study were associated with 478 recommended actions, of which the most common were related to staff training and education; changes to policy or procedure; and standardization of processes through protocols, clinical guidelines, or order sets.


  • Findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems, such as VA's EHR, will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of more rigorous inter-professional teamwork principles to improve outpatient communication and coordination.


  • Analysis was limited to selected reports of occurrences that were relatively severe.
  • Data do not reflect the overall rate or severity of delays in ambulatory settings.
  • The study did not control for additional variables, such as patient and facility characteristics, resource availability, or type of condition under evaluation.

This study was partly supported by HSR&D. Ms. Giardina and Dr. Singh are part of HSR&D's Houston Center for Quality of Care and Utilization Studies. Ms. King, Ms. Ignaczak, and Drs. Paull, Hoeksema, Mills, and Neily are part of VA's National Center for Patient Safety, Ann Arbor, MI. Work was performed as part of an ongoing collaboration between HSR&D investigators and the VA National Center for Patient Safety.

PubMed Logo Giardina T, King B, Ignaczak A, Paull D, Hoeksema L, Mills P, Neily J, and Singh H. Root Cause Analysis Reports Help Identify Common Factors in Delayed Diagnosis and Treatment of Outpatients. Health Affairs August 2013;32(8):1368-75.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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