VHA National Center for Patient Safety

The Patient Safety Centers of Inquiry (PSCI) program's goal is to develop, disseminate and implement clinically relevant innovations that improve patient safety throughout VA.

The U.S. Department of Veterans Affairs (VA) is pleased to announce the FY 2019 – FY 2021 Patient Safety Centers of Inquiry (PSCI) funding recipients. The VA National Center for Patient Safety (NCPS) administers the program and provides three years of funding for a PSCI to develop, disseminate and implement clinically relevant innovations that improve patient safety throughout VA. Some past examples of PSCI initiatives include the creation of toolkits for falls and moderate sedation for non-anesthesiologists, protocols for reducing hospital-acquired infections, suicide prevention and a cancer care tracking system amongst many others.

“The Patient Safety Centers of Inquiry program is the pre-eminent patient safety innovation network in the Veterans Health Administration,” said VA Secretary Robert Wilkie. “Since 1999, the interventions implemented through the PSCI program have significantly contributed to our Veterans receiving the safest care anywhere.”

The following ten PSCI proposals were selected out of 36 applications in a highly competitive review process. The interdisciplinary PSCI review committee consisted of patient safety experts in-cluding physicians, nurses, psychologists and pharmacists.

2019 – 2021 Patient Safety Centers of Inquiry (PSCIs)

VA Ann Arbor (Michigan) Healthcare System: 
The general theme of the Ann Arbor VA Patient Safety Center of Inquiry (PSCI) is preventing healthcare-associated complications. The PSCI’s specific goal is to promote the appropriate use of two common medical devices among Veterans: urinary catheters and peripherally inserted central catheters (PICCs). Overuse of these devices can lead to both infectious and non-infectious complications. The PSCI will provide tools and approaches that promote appropriate urinary catheter and PICC use to reduce healthcare-associated complications within VHA.

James J. Peters VA Medical Center (Bronx, N.Y.):
The Center for Medication Safety in Aging is a Patient Safety Center of Inquiry (PSCI) located at the James J. Peters VA Medical Center. The goal of this center is to serve as a dissemination hub for efforts to reduce adverse medication effects in older adults and those with dementia The center hopes to consolidate the current state of knowledge about
deprescribing best practices, engage VA innovators and facilities working in this area to form a network that shares practices and findings, and study implementation of these methods in VA settings.

Ralph H. Johnson VA Medical Center (Charleston, S.C.):
The Ralph H. Johnson VA Medical Center’s Patient Safety Center of Inquiry (PSCI) is dedicated to improving outcomes for Veterans transitioning between VA and non-VA care settings by specifically focusing on medication safety. The Charleston-based team plans to collect data to better understand the frequency and nature of Adverse Drug Events (ADEs) and potential ADEs among dual use Veterans. The PSCI further intends to develop a pharmacist-led medication safety program with initial deployment among high-risk community hospitalized Veterans and Veterans referred for specialty procedures in community settings. Finally, the PSCI will disseminate center-generated innovations within the VA Southeast Region (VISN 7) and nationally through partnerships with the VA Office of Community Care and the VA Pharmacy Benefits Management Service.

Michael E. DeBakey VA Medical Center (Houston, Texas):
The aim of the Houston VA’s Diagnosis Improvement Safety Center (DISCovery) is to prevent diagnostic errors (which affect 5 percent of US adults every year) by improving timely follow-up of abnormal test results. Failure to follow-up on abnormal test results in a timely manner is a major factor contributing to diagnostic
errors. The PSCI is working with clinicians and hospital leadership to develop and test a system to measure missed follow-up of abnormal test results. The system will provide clinicians and leadership feedback about these missed results, thereby enabling learning and improvement of subsequent test result follow-up and safer diagnosis.

Iowa City VA Health Care System:
The goal of the Iowa City VA's Center for Antimicrobial Stewardship and Prevention of Antimicrobial Resistance (CASPAR) is to develop and test automated risk-adjusted metrics for antimicrobial stewardship programs (ASPs) that are adaptable to the diverse care settings across VHA. The CASPAR objectives are: 1) to develop evaluation tools for ASPs and the Multi-drug Resistant Organisms (MDRO) prevention program that are adaptable to the diverse nature of care settings among VHA facilities, and 2) to develop an outcome tracking system for the ASP and MDRO prevention program utilizing information technologies.

VA Greater Los Angeles Healthcare System:
The VA Greater Los Angeles Healthcare System Patient Safety Center of Inquiry (PSCI) is planning to focus on transitions of care for complex Veterans, particularly elderly Veterans, with their transitions in and out of the hospital for surgical procedures and for medical conditions. In addition to transitions/handoffs (in and out of hospital), specific processes will be tested to look at impact on other designated areas of patient safety focus as well as impact on 30-day readmission and patient-centeredness/satisfaction. The goal is to test the transition-specific tools and processes in reduction of adverse events/targeted patient safety areas with subsequent dissemination to other sites.

VA Puget Sound Health Care System:
The VA Puget Sound Health Care System’s Supporting Primary Care Providers in Opioid Risk reduction and Treatment (SUPPORT) Patient Safety Center of Inquiry (PSCI) works with primary care providers to identify patients at high risk for adverse opioid-related outcomes and monitor patient opioid use and outcomes. Additionally, the PSCI provides guidance regarding tapering opioid prescriptions, and connecting patients with opioid use disorder with evidence-based pharmacotherapies to treat opioid use disorder in the primary care setting. The project also involves the creation of a database to track patients’ opioid doses, outcomes, contact with the team, and standardized note templates to facilitate assessment and pharmacologic treatment of opioid use disorder.

James A. Haley Veterans Hospital (Tampa, Fla):
The Patient Safety Center of Inquiry (PSCI) at the James A. Haley Veterans Hospital is dedicated to preventing adverse events related to mobility/immobility focusing on prevention of injurious falls, safe patient handling/mobility (SPHM) and pressure ulcer prevention. The PSCI examines best practices in fall and injury prevention, issues surrounding assisted falls, development of virtual simulation training for staff fall prevention education, evaluation of evidence on pressure ulcers and injury risk related to lift device slings and/or air transfer devices. Ongoing PSCI projects include the Falls Toolkit for Home Based Primary Care, evaluation of stand-bars for power wheelchair users, evaluation of novel compliant flooring for fall injury prevention and innovative applications of SPHM technology in rehabilitation.

Doris Miller VA Medical Center (Waco,Texas):
The overarching mission of the Doris Miller VA Medical Center's Patient Safety Center of Inquiry-VA Suicide Prevention Collaborative (PSCI-VASPC) is to develop, implement, and evaluate practical solutions to reduce suicide among Veterans who are not receiving VA care.The PSCI-VASPC has three specific objectives: 1) the PSCI-VASPC seeks to develop a collaborative organizational structure that connects VA and community suicide prevention services, 2) the center will share suicide prevention best practices between VA and the community to increase access for all Veterans, and 3) the PSCI-VASPC will develop a new program of effective, low-cost suicide prevention services for Veterans with emergent mental health needs that will capitalize on best practices for suicide prevention in VA and the community. The center will create products to support the spread of these practices to other VA medical centers and work to ensure these programs are sustainable. The PSCI-VASPC will serve as a national clinical innovation and dissemination center for best practices in suicide prevention for Veterans who receive care in the community.

White River Junction (Vermont) VA Medical Center:
The White River Junction VA Patient Safety Center of Inquiry’s (PSCI) goal is to adapt and pilot an evidence-based program to decrease suicide risk following psychiatric discharge in the VA treatment population. The PSCI also aims to identify additional high-risk VA patients who comprise clinically coherent groups that may be additional target populations for this intervention.