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VHA National Center for Patient Safety

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Patient Safety Centers of Inquiry (PSCI)

The VA NCPS Patient Safety Centers of Inquiry (PSCIs) are located in VA Medical Centers around the country and are focused on researching specific areas of patient safety and providing practical tools to improve patient safety at the bed-side. First funded in 1999, PSCI have made valuable contributions to the improvemen tof patient safety within VHA and beyond. For example, the PSCIs have contributed to:
  • Teamwork and simulation training
  • Application of usability testing and human factors design to Bar-Code Medication Administration
  • Safe patient handling and movement
  • Patient fall prevention and management

VA NCPS Patient Safety Centers of Inquiry (PSCI) Funded for FY 2016 Through FY 2018

VA NCPS manages the centers, which are an integral part of our program since 1999.

To be successful, a center is expected to develop, disseminate and, most importantly, implement clinically relevant innovations that improve patient safety in VHA facilities. Successful PSCIs provide specific tools for the field that can help to improve patient safety.

Examples of Contributions to VA's Patient Safety Efforts Include:

  • Improving electronic communication and alerts
  • Improving patient safety during moderate sedation
  • Improving home safety for high-risk patients as well as using human factors principles to reduce hospital-acquired infections and improve the sterilization of reusable medical equipment
  • Teamwork and simulation training
  • The application of usability testing and human factors design to bar-code medication administration
  • Breakthrough series collaboratives designed to reduce patient falls, reduce adverse drug events, and improve safety in high-risk settings
  • Extensive work in the areas of safe patient handling and movement and patient fall prevention and management
  • Studies of fatigue and its effects on clinicians’ performance
  • Improvement in the safety of drug prescribing practices and medication administration
  • Providing interventions to decrease preventable ADEs, including medication reconciliation and reduction in medication errors related to the ordering of chemotherapy for treatment of malignancy
  • Improving patient safety in the use of the electronic medical record
  • Reducing hospital-acquired infections
  • Using human factors principles to improve patient safety
  • Improving the safety of sterilization of reusable medical equipment

PSCI staff members also routinely publish articles in scholarly journals (more than 85 articles were published in FY 2015 alone).

Expectations for PSCIs

  • Develop, implement and demonstrate interventions in multiple VHA facilities to promote practices that improve patient safety by reducing adverse events or that replace or improve practices known to be associated with patient safety problems
  • Document changed practices and/or systems that reduce the likelihood of adverse events in multiple VHA facilities
  • Document the methods employed to foster changing practices and systems so that other VHA facilities can implement similar or identical changes to improve patient safety

  • Develop, test, refine and facilitate active distribution of tools and products specifically designed to promote patient safety, such as: clinical tools, cognitive aids, educational materials, measures of patient safety, policy reports; VHA information letters, handbooks, and/or directives; and others

  • Tools and other output should be evaluated for effectiveness and impact

Learn More

The PSCI program is funded through VA NCPS on a three-year cycle. Please contact

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