Actions Needed to Improve Use of Data on Adverse Events by Indian Health Service

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By Kaili Berg

July 20, 2023

Over a two year period, more than 27,000 adverse events were recorded by the Federal Indian Health Service (IHS), which provides care to roughly 2.8 million American Indians and Alaska Natives, including missed diagnoses and giving a patient the wrong medication. 

Trends with adverse events are currently tracked at the area and facility level through IHS Safety Tracking and Response, a web-based system that was implemented in 2020, but location specific information on those trends are not included in reports for IHS headquarters, the Government Accountability Office (GAO) said in a report released on July 10. 

The GAO is making two recommendations to IHS: That the agency regularly review and compare adverse event data of its geographical areas, and that it make improvements and use best practices in response to those trends. 

The GAO conducted this study because American Indian and Alaska Native (AI/AN) people are disproportionately affected by certain health conditions including a higher mortality rate compared with the overall U.S population, according to the report. 

According to the report, the GAO reviewed the agency’s use of information technology systems to manage patient care and monitor adverse events. IHS documents were also reviewed, including policies, meeting minutes and agendas. Lastly, GAO interviewed IHS officials from headquarters, area offices, and operating facilities. 

According to the report, beginning in July of 2023, IHS has committed to producing a quarterly report with adverse events data and trends, intended to identify and facilitate needed improvements.  

GAO is currently waiting to confirm what actions the agency will take in response to the recommendations made. Updated information will be provided later by GAO.

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Author: Kaili BergEmail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Staff Reporter

Kaili Berg (Aleut) is a member of the Alutiiq/Sugpiaq Nation, and a shareholder of Koniag, Inc. She is a staff reporter for Native News Online and Tribal Business News. Berg, who is based in Wisconsin, previously reported for the Ho-Chunk Nation newspaper, Hocak Worak. She went to school originally for nursing, but changed her major after finding her passion in communications at Western Technical College in Lacrosse, Wisconsin.