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VHA National Center for Patient Safety

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Cognitive Aids

We have developed a number or tools, training, and software to facilitate patient safety efforts at VA facilities around the nation, such as these cognitive aids.

Our focus is on improving and redesigning systems and processes − rather than a focus on individual performance, which is seldom the sole reason for an adverse event or close call. A previously unheeded or unnoticed chain of events most often leads to a recurring safety problem, regardless of the personnel involved.

Our previous set of cognitive aids were an important part of this effort and have been used successfully for years by interdisciplinary VA teams and patient safety staff members to help them develop systems-based solutions to numerous issues. We hope you will find the next version of them effective and useful tools in your patient safety efforts, too.

Root Cause Analysis

The RCA process is used to identify the basic or contributing causal factors that underlie variations in performance associated with adverse events or close calls. An RCA is a specific type of focused review that is used for all VA patient safety adverse events or close calls that require analysis.

An overview of VA's RCA process:

A detailed review of VA's RCA process:

In the VA, the term RCA is used to denote this type of focused review and the process must adhere to the procedures provided in the Patient Safety Improvement Handbook 1050.01.

VA patient safety reports, such as RCAs, are confidential under 38 U.S.C. 5705.

Learn More

Visit the section on our website devoted to RCAs.