Exhibit 1.

Types Of People Identified In Root Cause Analysis Reports Of Delays In Outpatient Diagnosis, Treatment, Or Both, National Center for Patient Safety, 2005–12

	Involved in:
Type	Number of reports	Percent of reports
Medical and surgical specialists	100	90.1
Generalists	98	88.3
Patients	65	58.6
Nursesa	48	43.2
Clerical or administrative support staff	47	42.3
Nurse practitioner or clinical nurse specialist	10	9.0
Other Health Care Professionalsb	33	29.7

Source Authors' analysis of 111 root cause analysis reports from the Department of Veterans Affairs National Center for Patient Safety, 2005–12.

^aIncludes registered nurses, licensed practical nurses, and unspecified types of nurses.

^bIncludes pharmacists, physical therapists, physician assistants and optometrists.