VA’s Patient Safety Progress

The Veterans Administration’s (VA) National Center for Patient Safety (NCPS) www.patientsafety.va.gov, a part of the Veterans Health Administration www.va.gov/health, uses a systems approach to problem solving focusing on prevention.

NCPS uses the multi-disciplinary team approach known as Root Cause Analysis (RCA) to study adverse medical events and close calls or near misses. The goal of each RCA is to find out what happened, why it happened, and what must be done to prevent the incident from happening again. Training programs, cognitive aids and companion software have been developed by NCPS to support RCA teams.

NCPS Patient Safety Information System www.patientsafety.va.gov is a de-identified internal, confidential, and non-punitive reporting system. It enables NCPS to electronically document and analyze patient safety information from across the VA. More than 1,000,000 RCA and safety reports have now been entered into the reporting system.

A Patient Safety Culture Survey enables NCPS to measure and report safety patient trends to leadership which enables VHA facilities to compare their patient safety culture to others outside of VHA. For example, parts of the survey are used by the HHS Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov.

In the mental health environment, a checklist was created to evaluate and improve the safety for inpatient mental health units. The checklist has resulted in an 82 percent decrease in deaths from suicide in VA inpatient mental health units.

NCPS has established a five step process for ensuring correct surgery involving verification of proper informed consents, standardized patient and procedure identification, marking the procedure site, reviewing relevant medical images, and providing for a timeout for safety prior to an invasive procedure or operation.

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