The first stop for medical care for many of those brave men and women who served in our nation’s armed forces is one of the 150 medical centers or nearly 1,400 facilities that together comprise the Veterans Health Administration, the single largest integrated health care system in the nation. Indeed, the VA system provided care to a whopping 5.8 million veterans in 2014 alone.

Unfortunately, a recently released report by the Government Accountability Office determined that the Department of Veterans Affairs, the agency that oversees all aspects of health care for U.S. vets, might be falling short when it comes to investigating adverse events.

What did the report find?

The GAO report, published late last month, found that from fiscal year 2010 through fiscal year 2014, the number of investigations conducted by the VA system into adverse events fell by an astounding 18 percent. During this same timeframe, the number of medical errors actually increased by 7 percent, while the number of vets receiving care jumped by 14 percent.

It wasn’t immediately clear, however, whether this drop in investigations was attributable to there simply being more minor mistakes not otherwise worthy of further investigation or an actual drop in the number of reports being reported by hospital staff.

What exactly is an adverse event?

An adverse event is essentially a preventable medical mistake resulting in harm to or the death of a patient. By way of example, consider surgical errors such as operating on the wrong patient or at the wrong site. Patient falls, medication errors and improperly sterilized medical equipment are also examples of adverse events.

When are VA hospitals supposed to investigate these adverse events?

In general, investigations — otherwise known as root cause analyses — are supposed to be launched in the aftermath of high-risk adverse events that stand a good chance of recurring. As far as lower-risk adverse events are concerned, hospital officials have considerably more leeway as to whether an investigation should occur.

How did the Department of Veterans Affairs respond to the report?

Curiously, VA officials were largely unaware of the reason why the number of investigations had dropped or what measures, if any, individual hospitals were taking to address the issue.

However, they did concur with the findings of the report and the suggestions made by the GAO regarding how to get to the core of the problem. Indeed, they indicated that the VA’s National Center for Patient Safety, which has oversight over these investigations, is now conducting its own review, which will be completed by November.

Here’s hoping the VA efforts to address this issue prove effective, and that our vets are able to get the level of care they need and deserve.