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VHA National Center for Patient Safety

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TIPS Newsletter

TIPS was the VA's official patient safety newsletter published quarterly (formerly bimonthly).

TIPS was retired in April of 2019 with the last issue released in January 2019 (below). This page is meant to be an archive of TIPS publications featuring all of the TIPS newsletters released from 2001 - 2019.

January/February/March 2019

  • VA selects director for National Center for Patient Safety: The U.S. Department of Veterans Affairs (VA) is pleased to announce the appointment of Dr. William Gunnar as the executive director of the VA National Center for Patient Safety (NCPS) in Ann Arbor, Michigan.
  • VA announces funding recipients for Patient Safety Centers of Inquiry: 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.
  • Putting a Face to a Name: Getting to know the patient safety managers in the Veterans Health Administration (VHA).
  • Documented secondary assessment decreases preventable VTE outcomes: The Veterans Healthcare System of the Ozarks (VHSO) initially adopted a VTE prevention program in 2009 utilizing a “Three Bucket” model to stratify patients into low, moderate, or high risk groups based on known VTE risk factors.

October/November/December 2018

  • Clinical alarm reduction - a method for success: The Clinical Alarm Committee of the Hunter Holmes McGuire VAMC (Richmond, VA) undertook a massive effort to reduce alarms by nearly 60%.
  • Psychologist works to make mental health units safe for suicidal Veterans: NCPS Psychologist and Field Office Director, Dr. Peter Mills, discusses how the Mental Health Environment of Care Checklist (MHEOCC) has helped reduce inpatient death by suicide in VA by more than 80% since 2007.
  • Putting a Face to a Name: Getting to know the patient safety managers in the Veterans Health Administration (VHA).
  • VA recognized for patient safety efforts: A team of researchers from the VA National Center for Patient Safety (NCPS), VA Pittsburgh Healthcare System and the VA Hudson Valley Health Care System were recognized by the ECRI Institute for their work to eliminate treatment errors.

July/August/September 2018

  • Case & commentary - suicide risk in the hospital: NCPS Psychologist and Field Office Director, Dr. Peter Mills, analyzes the fictitious account of a suicidal patient and offers insight on potential case management improvement.
  • Prescription questions? Ask a pharmacist: A VA Pharmacist, Dr. Eric Spahn, discusses two VA mobile applications designed to give Veterans more control and information over the management of their medications.
  • Putting a Face to a Name: Getting to know the patient safety managers in the Veterans Health Administration (VHA).
  • VA health care rated same or better than private hospitals: A recent study by The RAND Corporation found that Veterans receive the same or better care at VA medical facilities as patients at non-VA hospitals.
  • Cornerstone Recognition Program salutes patient safety: The Cornerstone Recognition Program recognizes the patient safety efforts of VA medical centers throughout the Veterans Health Administration. 

April/May/June 2018

  • The Patient Safety Huddle Board - A new tool for an old-fashioned business practice: The Patient Safety Huddle Board is a tool used to promote transparency, teamwork and provide a patient safety overview in real time.
  • Standardizing timeouts at the Phoenix VA Health Care System: The Phoenix VA Health Care System (PVAHCS) has a dedicated inpatient and outpatient Chief Resident in Quality and Patient Safety (CRQS). The chief residents lead a local threelegged curriculum teaching concepts in quality improvement and patient safety to internal medicine residents at the University of Arizona College of Medicine, Banner University Medical Center and PVAHCS.
  • 2018 National Patient Safety Goals (NPSGs): An overview of the 2018 National Patient Safety Goals (NPSGs) from The Joint Commission.

January/February/March 2018

  • The Daily Plan®: How Things Have Changed: There have been many changes to The Daily Plan® (TDP) since it was initially developed in 2007; yet, TDP
    continues to enhance patient safety by engaging the patient and/or their family in the health care and decision-making process.
  • Simulation Training Impacts Veteran Care at Truman VA: In January 2015, the Harry S.Truman Memorial Veterans’ Hospital (Truman VA) partnered with the VA National Center for Patient Safety (NCPS) to participate in the Hospital of the Future project.
  • NCPS Staff Awards: Two NCPS staff members receive national VA awards for their roles in NCPS patient safety related activities.
  • The Joint Commission Releases Environment of Care Recommendations with NCPS Input: This summer, The Joint Commission convened an expert panel which included world-renowned experts in suicide prevention and the design of behavioral health facilities. The panel, which included VA National Center for Patient Safety (NCPS) staff, contributed significantly to The Joint Commission’s recently published Special Report on Suicide Prevention in Health Care Settings.
  • Putting a Face to a Name: Getting to know the patient safety managers in the Veterans Health Administration (VHA).

October/November/December 2017 

  • Ensuring Safety From Afar: The Virtual Telesitter Solution: The Cincinnati VA Medical Center recently implemented a Virtual Telesitter Solution to at-risk of injury patients within the acute, critical care and long-term setting. This article discusses how they did it and how you can implement a similar program at your facility.
  • Simulation-Based Strategies to Teach the Universal Protocol and Timeouts for Invasive Procedures Occurring Outside the Operating Room:
    The VA National Center for Patient Safety (NCPS) provides insight on research that analyzes the effectiveness of different simulation-based strategies to teach the Universal Protocol and timeouts occurring outside the operating room. Additionally, NCPS has developed a "Time-out" app that can help facilities in teaching the Universal Protocol and timeouts.
  • Study Examines Factors Associated With Suicide Within One Week of Discharge From VA Psychiatric Facilities:
    The VA National Center for Patient Safety (NCPS) supports several Patient Safety Centers of Inquiry (PSCI) throughout the VHA system. One such PSCI at the White River Junction, Vermont VA Medical Center is focused on decreasing the rate of death by suicide following discharge. This study examines several root cause analyses (RCA) to better understand the prevalence of suicide immediately following discharge.
  • Putting a Face to a Name: Getting to know the patient safety managers in the Veterans Health Administration (VHA).

July/August/September 2017

  • Not Just Lip Service – Leadership in VA Gets Serious About High Reliability: NCPS Program Manager and Director of Clinical Training Programs Gary Sculli discusses the High Reliability Hospital (HRH) project with the Harry S. Truman Memorial Hospital’s (Columbia, MO) Associate Director.
  • Saving Lives: One Reversal at a Time: The Boston VA Healthcare System’s Patient Safety Manager gives a brief overview of how they implemented the AED Cabinet Naloxone Program in an effort to curb the opioid epidemic.
  • Putting a Face to a Name: Get to know members of the VA patient safety community.

April/May/June 2017

  • The Essential Role of Leadership in Developing a Patient Safety Culture: The Mountain Home VA Healthcare System's chief of quality management discusses The Joint Commission's Sentinel Event Alert, Issue 57 - The essential role of developing a safety culture and the various initiatives and programs available through the VA National Center for Patient Safety.
  • Joining Forces for Safer Care - Joint Patient Safety Reporting: The Department of Defense (DOD) and the Veterans Health Administration (VHA) collaborate on the Joint Patient Safety Reporting System (JPSR) - a standardized, simple way for safety-related incidents and issues to the appropriate patient safety professional.
  • Dedicated, Motivated, Safe and Sterile: The Central Alabama Veterans Healthcare System's (CAVHCS) Sterile Processing Service (SPS) is a dedicated team of professionals in the trenches of the patient safety improvement effort throughout the Veterans Health Administration (VHA).
  • Purchasing for Patient Safety: The Human Factors Engineering (HFE) section at the VA National Center for Patient Safety (NCPS) collaborates with stakeholders to ensure that products entering the VA supply chain are safe, reliable and efficient.
  • Passion for Patient Safety: A Doctor of Nursing Program (DNP) student fulfills her residency credits at the VA National Center for Patient Safety (NCPS).
  • Patient Safety Training - March 2017: A recap of the VA National Center for Patient Safety's (NCPS) recent Patient Safety Training Academy.
  • Putting a Face to a Name: Getting to know the patient safety managers in the Veterans Health Administration (VHA).
  • Tools to Reduce Perioperative Opioid-Related Risks: The VA National Center for Patient Safety (NCPS) Patient Safety Center of Inquiry at the Durham, NC VA Medical Center and colleagues discuss three tools for VA clinicians to help curb the nation's opioid epidemic.

January/February/March 2017

  • Lessons Learned: Fall and Fall Related Injury Prevention Virtual Breakthrough Series: The VA NCPS White River Junction, Vermont Field Office discuss the results of their recent Virtual Breakthrough Series on fall prevention.
  • Alberta Province Implements VA's Mental Health Environment of Care Checklist: Alberta Health Services has adopted NCPS' Mental Health Environment of Care Checklist. The checklist has contributed to an 82 percent decrease in deaths by suicide in VA inpatient mental health units.
  • Balancing Blood Sugar: Dr. Brian Burke from the Dayton VA and Pharmacist Sandra Hedin discuss the Choosing Wisely Hypoglycemia Safety Initiative.
  • Patient Safety Centers of Inquiry Update: New Patient Safety Measurement Display: The Patient Safety Center of Inquiry on Measurement to Advance Patient Safety (MAPS) is located within the Center for Healthcare Organization and Implementation Research (CHOIR) at the VA Boston Healthcare System.
  • Rocky Top Journey to High Reliability: The Mountain Home VA Healthcare System patient safety team review the ongoing journey toward high reliability.
  • Putting a Face to a Name: You're Patient Safety Team
  • 2017 Joint Commission National Patient Safety Goals

October/November/December 2016

  • NCPS Approach to Achieving High Reliability:&nbspNCPS Director Dr. Robin R. Hemphill and NCPS Director of Clinical Team Training Gary Sculli lay out a vision for VA to achieve High Reliability by creating a culture of safety throughout the Veterans Health Administration.
  • Pittsburgh's Center for Medical Product End-User Testing  Pittsburgh VA is the home to the Center for Medical Product End-User Testing (CMPET, an NCPS Patient Safety Center of Inquiry (PSCI). CMPET director Jamie Estock gives an update on the status and potential impact of the CMPET. 
  • The New Generation Risk Tool for VA HFMEA: PS team members Cassandra Zieminski and Stephen Kulju present the new HFMEA tool "Proactive Assessment for Safer Systems" or "PASS" which creates a digital workspace for completing HFMEAs in VA.
  • Great Catch - Magnetic Attraction: Louisville Robley Rex VAMC patient safety manager Crissy Knox and quality improvement specialist Kim Reibling highlight the 'good catch' of an MRI technician who had an interesting encounter with a Veteran.
  • NCPS Staffer Receives Prestigious Oliver Hansen Outreach Award: Recently retired NCPS staffer Linda Williams receives the Human Factors Ergonomics Society's (HFES) prestigious Oliver Hansen Outreach Award.
  • Chief Resident in Quality and Safety: An interview with Dr. Eric Yanke from the Madison VAMC who recently completed NCPS' Chief Resident in Quality and Patient Safety (CRQS) program and how it has helped him look at care from a systems perspective.
  • NCPS Patient Safety Boot Camp for Biomedical Engineers: NCPS biomedical engineer Katrina Jacobs discusses the BME boot camp and how it prepares newly hired BMEs to be a patient safety champion at their home facility.

Jul/August/September 2016

Contents include:
Pages 1-3. Good News About Access From Las Cruces, New Mexico
Pages 3-4. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA
Pages 5-7. Calling All Leaders: Paradigms for Embarking on the Just Culture Journey
Page 7. Putting a Face to a Name: Your Patient Safety Team
Pages 7-8. NCPS Offers a Just Culture Program

April/May/June 2016

Contents include:
Pages 1-4. A Road Map to Just Culture
Pages 5-6. Patient Medication Information Sheet Redesign Project
6. Putting a Face to a Name
Page 6. Remembering One of Our Own

January/February/March 2016

Contents include:
Pages 1-3. Making the Leap: The Story of How the VA NCPS Committed to Simulation as a Technique to Teach and Study Patient Safety
Page 3. Blueprint for Excellence" Focuses on High Reliability
Page 4. Human Factors as a Root Cause: Back to Blaming People?

July/August 2015

Pat Quigley and Julia Neily discussed VA’s fall reduction program at length in two podcasts that are available in the NCPS Falls Toolkit. The lead article in this issue of TIPS is meant to supplement the podcasts by offering the information in a print format, which can be used as a reference when developing a falls reduction program.

Pat Quigley is Associate Director, VISN 8 Patient Safety Center of Inquiry, and leads many of the center’s fall and injury reduction efforts. Julia Neily is Associate Director, VA NCPS Field Office, and has been involved in many quality improvement initiatives. 

  • Understanding the VA Fall Reduction Program: Falls reduction is a critical aspect of the VA patient safety program and a concern for caregivers around the nation. The key elements of VA’s efforts to reduce falls and injuries from falls are discussed.
  • Types of Falls and Suggestions to Reduce Them: Accidental falls, anticipated physiological falls and unanticipated physiological falls are defined. A number of efforts to protect patients from injury or to reduce severity are also discussed.

May/June 2015

  • High Reliability in the Operating Room: Targeting System Vulnerabilities: At the Birmingham VA Medical Center, an interdisciplinary team representing key areas of the operating room was formed to address a number of concerns with patient care that affect both VA and private sector hospitals.The article notes that three-quarters of the operating room staff felt substantial progress had been made because of the I-SLEEP initiative.
  • Safe Purchasing of Medical Devices: Purchasers of medical devices can have an effect on the safety of them by incorporating usability assessments as a part of their organization’s procurement process. As discussed in the article, the Nielsen and Shneiderman Heuristics tool can be used during the procurement process to reduce the likelihood of a device having design features that could put patients at risk.

March/April 2015

  • Health Care-Associated Infections: A Persistent Patient Safety Issue: Health care-associated infections are defined as infections acquired by patients through their contact with the health care system. Bacteria, fungi and viruses can be transmitted at any point of the patient care continuum.
  • Patient Safety Awareness Week, March 8-14, 2015: “United in Safety”: An annual education and awareness campaign for health care safety. The VA and Department of Defense scheduled 29 presentations for agency medical professionals to learn more about a wide range of patient safety programs and initiatives.
  • New Feature: “Meet the Author.” Listen to Dawn Sillars discuss her article in this short podcast.

January/February 2015

  • Joint Commission National Patient Safety Goals, 2015: The Joint Commission has revised National Patient Safety Goal 15.02.01 for home care facilities, which concerns home oxygen use and will be effective January 1, 2015.
  • System Challenges in the Inter-Facility Transport Process of VA Patients: Whether planned or emergent, there is a level of planning and coordination necessary to ensure the safe transition of patients to the appropriate care setting or to their next destination.
  • New Feature: “Meet the Author.” Listen to Maisha Mims discuss her article in this short podcast
  • Joint Commission National Patient Safety Goals 2015 Poster: Page 4 of the newsletter.

November/December 2014

  • Surgery Risks are Higher for Obese Patients: Obese patients have a much higher risk of potentially fatal complications following surgery. Reducing risks for obese patients can also lessen the potential occurrence of adverse events or close calls.
  • Outreach: Providing a Framework for Patient Safety: Staff members of the VA New York Harbor Health System are helping sup­port the development of a patient safety program within the Medical Services Division of the United Nations.
  • Chief Residents in Quality and Safety "Boot Camp": Chief Residents in Quality and Safety jumpstart their journey into quality improvement and patient safety at a “boot camp,” which includes an introduction to simulation as a tool for practic­ing teamwork and communication skills.

September/October 2014  

  • Shreveport: A Success Story: At the Overton Brooks VA Medical Center, we have made a concerted effort over the past year to not just improve, but excel at being a safe and high-quality surgical service. As a result, we have made tremendous strides in changing the culture of our surgical service.
  • Managing Fatigue: In late 2011, the Joint Commission issued a Sentinel Event Alert on health care worker fatigue and patient safety. A substantial number of studies have indicated that extended work hours for health care workers contribute to high levels of worker fatigue, which can result in an increased risk of adverse events and reduced productivity.
  • Improving Communications at the Memphis VA Medical Center: The OR Improvement Committee was com­missioned in January 2013 and charged to improve first case starts and reduce turnover times in the operating room, which has been a success, using such things as standardized hand-off and communication templates.

July/August 2014

  • A Toolkit: Patients At Risk for Wandering:The article provides an overview of patients “at risk” for wandering, as well as a variety of interventions to prevent patients from wandering or missing from VA facilities and grounds.
  • Stop the Line for Patient Safety: An interdisciplinary team effort at the Robley Rex VA Medical Center, Louisville, Ky., has led to a successful and inclusive approach to the “Stop the Line for Patient Safety” initiative, launched by the VA in April 2013.
  • A “Great Catch” for Patient Safety: The Veteran’s Health Care System of the Ozarks began the successful “Great Catch” program in January 2013 to promote the reporting of close calls, a critical aspect of VA’s patient safety program.

 May/June 2014

  • Staff Leadership Key to Enhancing the Root Cause Analysis Process: Root cause analysis team leaders and teams organized at the Charles George VA Medical Center, Asheville, N.C., include a diverse group of staff members, in an effort to promote the idea that patient safety is everyone’s concern.
  • A “Lean” Way to Improve Patient Event Reporting: Michael E. DeBakey VA Medical Center, Houston, Texas, transitioned from a voluntary paper-only incident reporting process to an electronic patient event reporting system, known as “ePER,” July 1, 2013, which led to a 245 percent increase in reporting.
  • Improving Communications by “Training the Trainer”: Staff members from 25 areas at the VA Greater Los Angeles Healthcare System were selected as trainers and came together January 14-15, 2014 for a Clinical Team Training “train-the-trainer session,” designed to facilitate training opportunities and implementation of crew resource management-based projects system-wide.

March/April 2014

  • Going an Extra Mile for Patient Safety: The VA Greater Los Angeles Healthcare System Patient Safety Advisory Team goes the extra mile to coordinate the evaluation, reporting and follow-up actions that involve patient safety and adverse events, encouraging staff members at all levels of the system to participate.
  • Reducing Falls at the VA Boston Heathcare System: The VA Boston Healthcare System took a multidiscipliary approach to falls prevention that has resulted in a substantial reduction in the number of falls, following its participation in a virtual breakthrough series.
  • Teaming Up to Identify and Locate Absent or Missing Patients: In July 2013, the Birmingham VA Medical Center formed a team to complete their annual Healthcare Failure Mode Effect Analysis: identifying and searching for an absent or missing patient. The team successfully developed specific actions and outcome to meet a variety set of challenges.

January/February 2014

  • Joint Commission National Patient Safety Goals, 2014: One new goal has been approved: (Goal 6) Improve the safety of clinical alarm systems. An Element of Performance for Goal 7 has also been revised: (NPSG.07.05.01) Implement evidence-based practices for preventing surgical site infections.
  • The "All-Day RCA": Conducting an RCA during a single business day, rather than over several days or weeks, has been very successful for the Central Arkansas Veterans Healthcare System.
  • 2014 Joint Commission National Patient Safety Goals Poster: The goals are presented in a summary format, to include which aspects of care each affects.

November/December 2013

  • Staying in Sync with High-Reliability Organizations: The VA’s patient safety program applies ideas from high-reliability industries, such as aviation, to target and eliminate system vulnerabilities, which is why NCPS staff members reviewed current industry practice at Delta Air Lines’ flight simulation center.
  • Working Together to Keep Veterans Safe: The VA Caribbean Healthcare System in San Juan, Puerto Rico, partici pated in a virtual breakthrough series with a goal of reducing 10% of fall events in acute care and 20% of fall injuries in long-term care.
  • The “Butler Tornados” Take on Falls Prevention: An interdisciplinary falls team who dubbed themselves “The Butler Tornadoes” were determined to reduce falls by 20% at VA Butler Healthcare’s “Village of Valor,” as a part of the virtual breakthrough series - but a 20% reduction turned out to be just the start.

September/October 2013

  • Identifying and Preventing Delirium in Elderly Veterans Using “old-fashioned care” to treat a high-risk population: The VISN 1 Patient Safety Center of Inquiry is developing a delirium prevention and monitoring program that has the potential to significantly enhance care provided to a high-risk group of elderly Veterans.
  • Patient Safety: It’s the Simple Things That Matter Most - Avoiding the Technology Trap: The article discusses how automated systems and their associ ated alarms are not as important as human responses to the information provided, since those responses are a reflection of the collective attitude toward technology management within a system.

July/August 2013

  • Enterprise Risk Management: An Introduction: The overarching purpose of the Enterprise Risk Management process is to protect an organization from risks that could interfere with its objectives and goals and mitigate risk, where it is unavoidable.
  • A New Spin on Wheelchair Safety: The Pittsburgh H.J. Heinz Community Living Center developed a new approach to wheelchair safety, based on an innovative way to identify the chairs and purchase of higher quality seat cushions.

May/June 2013

  • Clinical Team Training: Building High-Reliability in VA Health Care: Clinical Team Training is a new NCPS program that centers on building high-reliability teams by teaching specific behaviors that can reduce risk and mitigate the effects of error for hospitalized Veterans.
  • Chief Resident in Quality and Safety: Fulfilling a Pivotal Role in Patient Care: Chief residents represent tomorrow’s physician leaders: They educate junior residents, engage in patient safety efforts, and work closely with attending physicians and nursing staff in caring for patients.
  • A Synopsis of Patient Safety Awareness Week Programs, March 5-7, 2013: Running March 5-7, VA’s national program included more than 40 Live Meetings. Presenters included subject matter experts from NCPS and other VA activities who discussed a wide range of topics.

March/April 2013

  • VISN 8 Improvement Forum: Sharing Good Ideas: The forum provided a unique opportunity for facility leaders to consider initiatives that might increase safety and efficiency at their medical centers.
  • Beyond insulin pen sharing: hospital systems issues: A 2013 Patient Safety Alert prohibited use of multi-dose pen injectors on all patient care units at VA medical centers, with specific exceptions. The article provides guidance on use of the pens per the exceptions noted in the Alert.

January/February 2013

  • Joint Commission National Patient Safety Goals 2013: All current Goals and Elements of performance are outlined. No new goals were added for 2013.
  • Enhancing safety through the development of standard operating procedures and cognitive aids: A series of incident reports that concerned inconsistent processes for labeling specimens shed light on patient safety concerns and led to corrective actions.
  • Joint Commission National Patient Safety Goals Poster: The goals are presented in a summary format, to include which aspects of care each affects.

November/December 2012

  • Broadening the Impact of The Daily Plan®: Information on how The Daily Plan® has been used to enhance patient safety and patient empowerment is offered, as well updates concerning its new use in ambulatory care areas.
  • Improving Transitions for Mental Health Patients: Using process improvement, the emergency department and psychiatric emergency services staff at the VA Puget Sound Health Care System have developed a tracking tool to facilitate patient-centered care and reduce communication breakdowns.
  • Using the Patient Safety Assessment Tool (PSAT) to Conduct a Prospective Risk Analysis: During the construction and activa tion of a community living center at the VA Puget Sound Health Care System, an interdisciplinary team identified potential risks using PSAT, a tool developed by NCPS.

September/October 2012

  • The Safe Day Call: The daily 15-minute call keeps staff informed, the lines of communica tion open, breaks down stove-piping and helps resolve emergent issues.
  • Redesigning Medication Alerts to Support Prescriber Decision-Making: The article discusses a study aimed at improving medication order checks, which
  • Developing a Culture of Safety: A summation of NCPS’s efforts to develop and nurture a culture of safety throughout the Veterans Health Administration.

July/August 2012

  • Risk awareness and patient safety: Though often understated, risk mitigation has been a key aspect of each NCPS program and initiative since its establishment.
  • Contrast media administration errors involving allergies: The two types of contrast media, iodinated and paramagnetic, can cause complications when administered to patients susceptible to adverse reactions.
  • Reducing the risk of Veteran misidentification: Learning how to better the patient identification process through studying incident reporting trends, analyzing close calls, and involving Veterans and staff in an improved process can significantly advance a facility’'s patient safety program.

May/June 2012

  • Effecting change with the virtual “Breakthrough Series” model: Respiratory failure following surgery is a high risk, but potentially preventable adverse event, making it a prime target for a “Break through Series,” using Agency for Healthcare Research and Quality Patient Safety Indicators.
  • Building trust through communication: Speaking with a patient or family member about an adverse event requires enhanced communication skills, which is the focus of the article.
  • Patient Safety Assessment Tool (PSAT): An overview: PSAT was developed as a cognitive aid for use by patient safety professionals when conducting surveys and became a Web-based tool in 2011.

March/April 2012

  • Summary of fourth national patient safety survey: NCPS conducts a VHA-wide patient safety culture survey every three to five years to assess patient safety culture. Four national surveys have been conducted since 2000, the latest occurring in 2011, with more than 48,000 participants.
  • Avoiding a single point of failure: Fault tolerance and patient safety: NCPS programs focus on the reduction and prevention of inadvertent harm to patients as a result of their care, using a number of tenets adapted from fault-tolerance design principles.
  • Getting ‘SERIOUS’ about medication reconciliation: The SERIOUS model improves the medication reconciliation process by breaking it down into small steps that can be performed by different members of a health care team.

January/February 2012

  • National Patient Safety Goals, 2012: The Joint Commission has approved one new National Patient Safety Goal (NPSG) for 2012. The new goal, NPSG.07.06.01, is focused on catheter-associated urinary tract infections (CAUTI).
  • Preventing Fires in the OR: OR fires are rare, but can have serious and debilitating consequences. Fortunately, they occur in an extremely small percentage of the approximately 65 million surgical cases each year.
  • National Patient Safety Goals, 2012: The goals are presented in a summary format, to include which aspects of care each affects.

November/December 2011

  • Improving patient safety through human factors engineering and usability testing: Human factors engineering is a discipline used to study the mental and physical capabilities, characteristics, and limitations of humans. It is a key factor in usability testing, which examines how effectively humans interact with tools and systems.
  • Are prescription labels understood by our Veterans? A snapshot of results from a new study: The project evaluated Veterans’ literacy with current VA prescription labels, as well as comprehension and satisfaction with a proposed new patient-centric label, using an evidence-based, patient-centric evaluation model.

September/October 2011

  • Introducing our new director, Robin Hemphill, M.D.: Dr. Hemphill is the new deputy chief patient safety officer and direc tor, National Center for Patient Safety. She is also continuing her practice as an emergency medicine physician.
  • Patient safety fellowships: a perspective: Maggie Mizah, a VA pharmacist serving at the VA Pittsburgh Healthcare System, relates her experience as a patient safety fellow, 2010-2011.
  • New surgery data indicates reduced harm to patients: A VA report published in the Archives of Surgery online edition indicates a continued overall decrease in the number and severity of wrong site surgeries in the VA.

July/August 2011

  • Patient Satisfaction and Patient Safety: Outcomes of Purposeful Rounding: The availability of a nurse and nursing presence at the bedside are among the predictors of patient satisfaction
  • Research on Veteran Comprehension of VA Prescription Labels: The research includes an evidence-based and patient-centric evaluation model to enhance patient comprehension of prescription labels.
  • Update: Patient Safety Curriculum Program for Faculty and Residents: The Patient Safety Curriculum program was first piloted in 2003, with a focus on faculty development workshops. High-fidelity simulation was added in 2010.

May/June 2011

  • Enhancing Clinicians’ Communication and Teamwork Skills Through the Use of High-Fidelity Simulators: Three NCPS programs use high-fidelity simulators to improve participants’ teamwork and communication skills during training sessions held around the nation: Medical Team Training, Nursing Crew Resource Management, and Patient Safety Curriculum for Faculty and Residents.
  • Nursing Crew Resource Management (NCRM) Update: In 2010, NCPS partnered with the Office of Nursing Service to launch NCRM. This article details the progress made since then at the 14 nursing units in nine VA facilities where the program is underway.

March/April 2011

  • New Moderate Sedation Toolkit for Non-Anesthesiologists: The VISN 6 Patient Safety Center of Inquiry (PSCI), Durham, N.C., in partnership with Duke University Medical Center staff, has developed a comprehensive toolkit to support non- Anesthesiologists who conduct moderate sedation.
  • Medication Reconciliation: The Patient Behind the List: When reflecting on how medication rec onciliation fits into the safety and quality of care provided at VA facilities, it can be useful to take a step back and place oneself in the shoes of the patient.
  • ‘Medical Team’ Approach Reduces Operating Room Mortality Rates: A VA study concludes that Medical Team Train ing improves communication, teamwork and efficiency in VA operating rooms, resulting in significantly lower mortality rates.

January/February 2011

  • Joint Commission National Patient Safety Goals, 2011: The Joint Commission has made few changes to the National Patient Safety Goals that take effect January 2011, though some are planned for July 2011. This article highlights the changes and provides a poster concerning the goals and elements.
  • Preventing Wheelchair-Related Falls: An initiative developed by VAMC Martinsburg, W. Va., has reduced falls from wheelchairs at the facility’'s Community Living Centers.

November/December 2010

  • NCPS Patient Safety Centers of Inquiry (PSCIs): An Introduction: PSCIs were first funded in 1999 and have made valuable contributions to the improvement of patient safety within VA and beyond.
  • Participating in Proactive Nursing Rounds: Participating in proactive nursing rounds on an hourly basis is truly a win-win situation for everyone involved.
  • A new Effort to Promote Fire Safety in the Operating Room (OR): The San Francisco VA Medical Center developed “The Surgical Fire Assessment Protocol” checklist to reduce the risk of fire in the OR

September/October 2010

  • Biomedical Engineers: Teaming up for Patient Safety: The breadth of NCPS biomedical engineers’ duties and responsibilities is discussed.
  • How a Local Patient Safety Initiative is Becoming a National Priority: Background on efforts to redesign VA medication labels and make them more patient-friendly.
  • When VA Patient Safety Professionals Need Information: Suggestions on how best to request searches of SPOT and to enter data into the system.

July/August 2010

  • Promoting Proper and Correct Patient Identification – A Transfusion Medicine Perspective: Blood transfusion is one of the most common, yet high-risk procedures performed on hospital inpatients. Proper and correct patient identification is important to ensure patient safety during transfusion.
  • Developing a Culture of Safety: One VA Facility’s Story: Staff members at the Kansas City VA Medical Center have taken a wide range of actions to improve patient safety at their facility.

May/June 2010

  • The VA and Patient Safety: It has been just over 10 years since the Institute of Medicine published its landmark study on patient safety, To Err is Human. NCPS was also established in 1999. Veterans have a right to ask, “What has the VA accomplished?” This article answers that question.
  • Your VA Patient Safety Program at Work: Highlights of major NCPS programs and initiatives developed during the past 10 years.

January/February 2010

  • Joint Commission National Patient Safety Goals, 2010: The Joint Commission has made significant changes to the National Patient Safety Goals for 2010. This article highlights the changes and provides a poster concerning goals and elements.

November/December 2009

  • Communicating Safety Through the VA's Electronic Health Record: This article discusses ways to improve communication among VA caregivers, which is increasingly dependent upon VA’s electronic health record, the Computerized Patient Record System.
  • Fighting Both the "Regular" and the New 2009 H1N1 Flu: Although "regular" or seasonal flu occurs throughout the fall, winter, and spring, the situation this year is extraordinary because of the H1N1 flu. This article summarizes the VA’s response.
  • Use of Color-Coded Wristbands: This article discusses why NCPS does not plan to pursue standardization of color-coded wristbands for events such as falls, do not resuscitate (DNR), or allergies.
  • Spotlight on Patient Safety and Recalls: Though patient safety alerts and advisories share a Web site with product recalls, members of each program have different duties and responsibilities, which this article discusses.

September/October 2009

  • A New Look at Aggregated Reviews: More than 5,000 Aggregated Root Cause Analysis reviews have been recorded in the NCPS Patient Safety Information System database. This article offers what has been learned during the initial efforts to categorize these aggregated reviews.
  • Evaluating a “Hand-Off Communication Checklist” Process: James A. Haley Veterans Hospital developed a hand-off checklist in 2005 and rolled it out in 2006. After three years of use, the patient safety staff felt it was time to review this document to see if its daily use was sustained or to edit it, if needed.
  • Summary of Root Cause Analyses Concerning Sleep Apnea: Sleep disorders have become an increasingly well-recognized health concern, underlined by the fact that the VA operates 85 sleep labs. A search of the NCPS Patient Safety Information System database found 12 root cause analyses associated with sleep apnea, which this article explores.

July/August 2009

  • The Daily Plan®: Involving Patients in Patient Safety: The Daily Plan® enhances patient safety and patient involvement. The article provides background information about the plan and reinforces the concept that helping patients understand their care is the right thing to do.
  • A Review of NCPS’ Fiscal Year 2009 Patient Safety Initiative (PSI: For the past four years, NCPS has allocated funds for field-generated patient safety initiatives that enhance patient safety across the VA. Of the 31 proposals submitted for fiscal year 2009, 18 were funded.
  • Nursing Crew Resource Management (NCRM): Patient Safety for Front-Line Nurses: NCRM will teach nurses the core principles found in the disciplines of patient safety and human factors. It will also provide tools that can be implemented on nursing units to build teamwork, improve performance, and manage human error.

May/June 2009

  • The Root Cause Analysis (RCA) Process, One Step at a Time.: The outlines each step in the RCA process, pages 1-3; provides web site references and related information, page 4.

March/April 2009

  • Multiple-Dose vs. Single-Dose Drug Delivery Systems: This article discusses whether to stock multiple-dose or single-dose vials of a medication. Two issues are commonly evaluated: which option can reduce costs and which option can improve patient safety.
  • Delay in Outpatient Diagnosis and Care: Of 1,124 root cause analysis (RCAs) associated with delay of diagnosis and care, 18 percent were linked to outpatient care. A variety of actions were implemented by RCA teams to reduce or eliminate future occurrences.
  • Banning Tobacco Use in Acute Inpatient Psychiatric Units: Smoking bans on locked, acute inpatient psychiatric units are feasible in the Veterans Health Administration – and can offer many health and safety benefits to patients and staff.

January/February 2009

  • Annual edition on Joint Commission Patient Safety Goals: Pages 1 and 4 provide an overview of the Joint Commission National Patient Safety Goals for 2009.
  • Joint Commission 2008 Patient Safety Goals Poster: Pages 2 and 3 are combined to create an 11 x 17 inch poster that offers a summary of goals and requirements “at a glance.”

November/December 2008

  • Disruptive Behavior in Health Care Settings: Patient safety is affected by disruptive behavior. In a hostile environment, communication is hindered, which can have a direct impact on patient outcomes.
  • Developing a “Soft” Door to Prevent Suicides: The invention of a “soft” door by two VA employees has the potential to reduce suicides in mental health wards across the nation.
  • Three Hospitals Unite for Patient Safety: The hospital affiliates came together the year to bridge their patient safety programs and improve staff education by establishing the Tri-Hospital Best Practices Council.
  • The Daily Plan®: Synopsis of a Study on the Initial Pilot: One result that was nearly 70 percent of the patients agreed or strongly agreed that having The Daily Plan® made provided them with information that helped improve their care.

September/October 2008

  • Improving the Safety of Anticoagulation Therapy: A VA anticoagulation work group has addressed anticoagulation therapy safety issues identified by IHI and the Joint Commission. Specific guidance on implementing these recommendations will appear in a VA directive.
  • Case Study: Biomedical Engineering: Human factors engineering problems became apparent when a pathologist noted abnormally high test results while working with certain test tubes.
  • News From the Patient Safety Reporting System (PSRS): An overview of PSRS is offered, to include contact information. PSRS is an external, confidential, voluntary, non-punitive reporting system that has been in use since 2001.

July/August 2008

  • Taking a Practical Approach to Hand Hygiene: The Ann Arbor (Michigan) VA Healthcare System has developed a hand hygiene initiative focused on creating practical solutions to challenges faced by VA and non-VA hospitals nationwide.
  • New Challenges in Acute Mental Health Wards: Acute mental health admissions are rising and a new mix of patients require a higher level of care.
  • Hospital and Nursing Home Bed Safety: While death or injury due to entrapment is rare, it’s important to recognize that part of our veteran population is at risk, in particular the elderly.

May/June 2008

  • Making Falls Reduction a Full-Time Job: Having an advance practice nurse coordinate a facility'’s falls reduction program, combined with a facility'’s commitment to falls reduction, can lead to significant improvements.
  • VA’s Strategic Nap Program: Naps have been shown to dramatically increase alertness and performance in the laboratory and in field studies. This is true in health care and other high-risk settings. The program directly addresses the issue of what can be done about fatigue.

March/April 2008

  • Developing a Rapid Response System: The article discusses how a Rapid Response System is being developed and piloted at the North Florida/South Georgia Veterans Health System.
  • About the Patient Safety Fellowship Program: The article provides a brief overview of the new program and a method to contact NCPS for further information.
  • How a Good Idea Got Better: Staff members at the VA Medical Center, Muskogee, Okla., were initially cool to the idea of creating a patient safety committee – but the committee’s effectiveness has become apparent to all concerned.
  • Using Linear Programming for Health Care Modeling and Prediction: Simple spreadsheet-based programs can shape raw data into a decision-making tool, as well as eliminating the need for the user to have advanced mathematical skills.

January/February 2008

  • Annual edition on Joint Commission Patient Safety Goals: Pages 1 and 4 provide an overview of the Joint Commission National Patient Safety Goals for 2008.
  • Joint Commission 2008 Patient Safety Goals Poster: Pages 2 and 3 are combined to create an 11 x 17 inch poster that offers a summary of goals and requirements “at a glance.”

November/December 2007

  • Preventing Health Care–Associated Infections: Empowering Patients and Engaging Staff: The article discusses VHA’s nationwide prevention initiative aimed at eliminating MRSA (Methicillin-resistant Staphylococcus aureus) infections via the ‘ZEROing in on MRSA Initiative.’
  • How Long do You Wash Your Hands?: Hands coated with “Glo-Germ,” a tool for teaching hand washing with soap and water, are depicted to show the effect of hand washing during a 15-second period.
  • “Ask Me If I’ve Washed My Hands”: A hand hygiene initiative developed at the James H. Quillen VA Medical Center is discussed and a brief overview of hand washing is offered.
  • Where Can You Find More Information on Hand Hygiene?: The article provides a detailed guide to hand hygiene references offered on the NCPS web site.

September/October 2007

  • Medication Reconciliation: This article provides background information on this issue and suggestions on how to reduce related adverse medication events.
  • 2007 Patient Safety Initiative: The PSI is an opportunity for patient safety managers to apply for funding for creative patient safety projects. The article highlights successes during PSI 2006 and describes the proposals funded in 2007.

July/August 2007

  • VA Patient Safety Professionals Speak Out: Patient safety managers and officers discussed aspects their programs, as well as their hopes for the future of VA patient safety.
  • Broadening the Utility and Understanding of Patient Safety Data: NCPS has combined a Primary Analysis and Classification project with a new Natural Language Processing tool to better extract, understand and organize information derived from SPOT.

May/June 2007

  • 2006 Patient Safety Initiative: The PSI is an opportunity for patient safety managers to apply for funding for creative patient safety projects. The article discusses this first PSI and describes the proposals funded.
  • How to Customize SBAR for Your Facility: Following a Medical Team Training session at the VA Northern Calif. Health Care System, the nurse executive team decided to implement SBAR and develop a related CPRS tool.
  • Teams Honored for Patient Safety Design Initiatives: Four teams were recognized for taking a creative approach to design during the VA National Patient Safety Managers Conference, March 2007.

March/April 2007

  • Look-Alike/Sound-Alike Medications — What can be Done?: Look-alike/sound-alike medications are a significant cause of adverse events and close calls. This article summarizes the problem and offers recommendations to help mitigate it.
  • Adult Learning — It’s Important to Patient Safety: This article discusses learning concepts that may be useful when bringing new caregivers into root cause analysis teams or at other times when teaching adults about patient safety.
  • “Out-of-the-Box Failures”— Problems With Disposable, Invasive Devices: During a recent review of a number of RCAs, the teams involved encountered difficulties finding a specific reason as to why an item broke inside a patient. This article discusses some of the likely causes.

January/February 2007

  • JCAHO National Patient Safety Goals for 2007: Selected highlights of the new goals and new aspects of the pre-existing goals are provided. Pages 2 and 3 of this issue have been converted into a poster summarizing the application of the goals for easy reference.

November/December 2006

  • Root Cause Analysis: Bridging the Gap Between Ideas and Execution: A summary of a VA New York Harbor Healthcare System project that sought to identify factors that influence whether its RCA action plans were implemented and effective.
  • Specimen Management in the Laboratory – Opportunities for Improvement: A review of RCA reports from 2000 to 2006 found a number of adverse events related to specimen management in the laboratory.
  • Communication Matters – Part III: Becoming Active Healthcare Citizens: This final installment of a series on communication focuses on the need for patients to become “active healthcare citizens.”

September/October 2006

  • What’s the Patient Safety Improvement Corps (and what’s in it for me)?: The article provides an overview of the creation and implementation of the Patient Safety Improvement Corps, as well as what it can mean for patient safety managers/officers.
  • “And the ‘EYES’ Have It”: Ear Drops, That is…: Mix-ups when dispensing or administering ear and eye drops are not uncommon and can be reduced.
  • Communication Matters – Part II: Provider-to-Provider Communication: Effective communication between healthcare professionals is critical for good patient care.

July/August 2006

  • Broad Trends Identified by the 2005 Patient Safety Survey: One of NCPS’ primary goals is to improve the culture of patient safety at VA hospitals. The 2005 survey offers insight into the development of this culture.
  • Patient Harm from Anatomic Surgical Specimen Management in the OR: Surgical patients can suffer the consequences when anatomic specimens produced from surgical procedures are lost, mislabeled, or processed incorrectly
  • Communication Matters: Part 1 — Talking with People: Being a good communicator with patients and colleagues should be at the top of every healthcare professional’s list.

May/June 2006

  • Tablet Splitting: Table Splitting is a common practice often recommended by providers and implemented by healthcare systems. It has many benefits, and consideration of both drug and patient characteristics ensures safe and appropriate use.
  • New Directive: Preventing Retained Surgical Items in Surgical Procedures: During a surgical procedure, surgical teams employ standard “tools of the trade,” usually described in three categories: instruments, sharps, and sponges. Infrequently, one of these items can be accidentally left inside a patient after a surgical procedure is concluded.
  • Adverse Events Related to Do Not Resuscitate (DNR) Orders: DNR orders come with strong ethical implications. We would never want to withhold resuscitation when chosen to be attempted; nor conduct a code when DNR decisions have been conscientiously reached and agreed upon.

March/April 2006

  • Medical Team Training Program: The MTT program will be coming to VAMCs around the nation in the next few months. This article discusses the MTT process and highlights how the program has been succesfully begun at a number of facilities.
  • Beyond Preventive Maintenance: The article discusses how one facility reprogrammed IV pump medication menus by taking a team-based, systems approach to problem solving.
  • Using Caution with Fentanyl Patches: The use of fentanyl patches has changed the way pain medication is administered, but with convience come a number vunerablities, as this article shows.

January/February 2006

  • JCAHO National Patient Safety Goals for 2006: Selected highlights of the new goals and new aspects of the pre-existing goals are provided. Pages 2 and 3 of this issue have been converted into a poster summarizing the application of the goals for easy reference.

November/December 2005

  • Analyzing Missing Patient Events at the VA: A review of RCAs and Aggregate Reports has led to a better understanding of where and when wandering and elopement events occur.
  • VISN 8 Patient Safety Center of Inquiry — Preventing Wandering and Associated Adverse Events: The mission of the VISN 8’s PSIC is to prevent adverse events associated with mobility and immobility; to design and test safety “defenses” — to include technologies — for patients, providers, and organizations.

September/October 2005

  • VAMedSAFE: THE VISN 12 Center for Medication Safety: An introduction to the mission of the Patient Safety Center of Inquiry, Hines, Ill. The center identifies, tracks, and addresses preventable adverse drug events in the VA healthcare system.
  • Improving the Bar Code Medication Administration (BCMA) System at VHA: A synopsis of the results of a Collaborative Breakthrough Series, cosponsored by VA and NASA, that focused on improving the safety and efficiency of the BCMA system.
  • Diagnostic Adverse Drug Events Series: Article 1, Contrast Media Events: NCPS has received more than 350 reports of adverse events related to the use of contrast media (contrast dye). A number of the events are discussed and recommendations are offered to reduce or eliminate risk to patients.

July/August 2005

  • Developing a Hands-On Museum: Starting a collection of devices to illustrate the good and the bad of human factors engineering can help RCA teams better conduct their duties and enhance a facility's patient safety program.
  • Improving Chemotherapy Safety: Introduction to the Patient Safety Center of Inquiry for Chemotherapy Safety: a summary of goals and activities.
  • A New, Simplified Approach to Medication Close Call Reporting: VAMC West Palm Beach has developed a user-friendly, computer-based format that has resulted not only in a significant increase in reporting, but in a better understanding of specific actions required to reduce adverse medication events.

May/June 2005

  • What Keeps You Awake at Night: In 2003 and in 2004, NCPS conducted several day-long patient safety training sessions for VA facility leadership teams. This article concerns how these VHA leaders answered five specific questions that concern patient safety.
  • Read-Back – It’s Not Just for Nursing Units: The JCAHO patient safety goals that deal with high-risk communication haven't been implimented consistenly in diagnostic, patient care areas of hospitals, such as radiology and nuclear medicine.
  • Hand Hygiene and Diarrheal Diseases in Healthcare Settings: Although using an alcohol-based hand rub is usually the best way to routinely decontaminate hands, there are particular times when washing with soap and water and increasing the use of gloves are the best ways to prevent healthcare-associated infections.
  • Safety Spotlight: Telephone Triage Protocol: A discussion of the systems-based problems that developed when a patient called a facility's telephone triage line to complain of shortness of breath, tightness in his chest, and pain in the left shoulder.

March/April 2005

  • Top Ten Myths about Patient Safety Information System (SPOT) Safety Reports: A number of misconceptions about safety reports have come to light over time: This article discusses the top ten myths about them and why these reports can be extremely valuable.
  • Patient Safety Spotlight -- Decubitus: According to the National Decubitus Foundation, one-in-ten hospital patients, one-in-eight home care patients, and one-in-four nursing home patients suffer from bedsores.
  • When Tourniquets are Left Behind: In more than 90 reports submitted to SPOT, every tournique that was found to have been left on a patient was discovered by someone other than the caregiver who had placed it on the patient.

January/February 2005

  • Summary Highlights of the 2005 Patient Safety Goals: Brief summary of Goals 1-12 with additional references when applicable.
  • JCAHO National Patient Safety Goals for 2005: Selected highlights of the new goals and new aspects of the pre-existing goals are provided. Pages 2 and 3 of this issue have been converted into a poster summarizing the application of the goals for easy reference.

November/December 2004

  • Medical Team Training — An Overview: Poor communication among clinicians is a leading source of adverse events in healthcare as evidenced by JCAHO goals related to communication. To address the need for improved communication, the VA developed Medical Team Training.
  • Safety on Inpatient Psychiatry Units — Always a New Challenge: It seems there are never enough eyes available to discover potential problems when working to ensure patient and staff safety on an inpatient psychiatry unit! This article discusses a specific incident and follow-on remedial actions.

September/October 2004

  • Ensuring Correct Surgery and Invasive Procedures: The new directive includes JCAHO’s requirements noted in the Universal Protocol, effective July 1, 2004. The article summarizes the changes and provides references.
  • Reducing the Vulnerability of Retained Surgical Sponges: Leaving sponges inside patients who undergo surgical procedures is a serious and persistent problem in healthcare throughout the world.

July/August 2004

  • How to Make the Most of Action and Outcome Measures: Helping RCA teams come up with actions that will minimize or prevent the root cause from happening again.
  • Unit Dose – It’s the Gold Standard for a Reason: Designed to improve medication safety, unit dose drug distribution has been the practice standard in health systems for decades.

May/June 2004

  • Introducing the Falls Toolkit: The kit is designed to provide comprehensive, practical, evidence-based resources for the prevention of falls and fall-related injuries, as well as provide advice for developing a falls prevention program.
  • Falls Resulting in Patient Injury or Death: Root cause analyses that involve falls, in which the patient experienced a fracture, another injury, or death, occur in a variety of locations and varied situations.
  • Preventing and Responding to Myiasis: Myiasis is a relatively rare occurrence in the United States and in U.S. healthcare facilities, but it does happen — even in hospitals without an obvious problem with cleanliness.

March/April 2004

  • The Best Way to Make Your Dreams Come True is to Wake Up: Thanks to the analyses of many suicide and parasuicide events and close calls, a small team at NCPS was able to categorize a convenience sample of 400 suicide-related RCAs from across the country in FY02.
  • Reducing Falls and Fall-Related Injuries in the VA System: Falls are a leading cause of adverse events in the Veterans Health Administration. From 2001 to 2002, we conducted a Breakthrough Series to address this issue.
  • National Patient Safety Awareness Week: March 7 - March 13, 2004: Patient Safety Awareness Week provides an excellent opportunity to promote facility-wide patient safety initiatives.

December 2003

  • Update on JCAHO Patient Safety Goals for 2004: This special issue provides guidance and details concerning the 2004 goals.
  • New Patient Safety Goal 7: Information on CDC recommendations for hand hygiene in regards to the new patient safety goal.
  • Modified Patient Safety Goal 2: Information on JCAHO’s expansion of Goal 2(a) to help prevent the occurrence of miscommunication when reporting “critical test results.”

October/November 2003

  • Improving Emergency Airway Management Within the VA: An emergency airway management event occurs more than 11,000 times a year outside the operating room at VA facilities.
  • Lessons learned from the big blackout of August 2003: VA facilities affected by this summer’s blackout rose to the challenge of carrying out basic services in support of patient safety.
  • Preventing Surgical Fires at the Birmingham, Alabama VAMC: Discussion of a collaborative effort underway to educate and train staff in the VAMC’s process for prevention of such fires.

August/September 2003

  • Surgical Fires and Patient Surgical Burns: These types of fires are a potentially devastating yet preventable adverse event; discusses practical ways to avoid such fires.
  • The Rationale Behind the Five Steps of the Ensuring Correct Surgery Directive: Answers a number of questions from the field concerning the rationale behind the directive's steps.
  • Power Failures in the Operating Room Suite During Open Heart Surgery: Discusses reports from two VA facilities regarding actions following the loss of electrical power in the operating room suite during open heart surgery.
  • Martinsburg VA Medical Center Launches Close Call Reporting Program: Discusses inauguration of a Close Call Reporting Program, February 2003; uses a modified "Reason's Swiss Cheese Model."

June/July 2003

  • NCPS Patient Misidentification Study: A Summary of Root Cause Analyses: Patient Misidentification has been highlighted as a serious issue in medical literature; within the NCPS RCA database more than 100 RCA reports involving patient misidentification were noted.
  • Ensuring Correct Surgery Outside the Operating Room: The risk of performing an incorrect site procedure may be even higher for procedures and surgeries performed outside the operating room; checklist provided to help avoid problems.
  • High Reliability Team Training: NCPS has recruited several facilities to participate in a three-month pilot program to evaluate the effectiveness of team training in the VHA.

December 2002

  • Special Edition: JCAHO Patient Safety Goals 2003:
    • Goal #1: Improve the Accuracy of Patient Identification
    • Goal #2: Improve the Effectiveness of Communication Among Caregivers
    • Goal #3: Improve the Safety of Using High-alert Medications
    • Goal #4: Eliminate Wrong-site, Wrong-patient and Wrong-procedure Surgery
    • Goal #5: Improve the Safety of Using Infusion Pumps
    • Goal #6: Improve the Effectiveness of Clinical Alarm Systems

July/August 2002

  • Could You Say That Again . . . It’s a Little LOUD in Here (excessive noise levels: Excessive noise levels associated with magnetic resonance imaging (MR) procedures have been known to be a problem for many years.
  • The Patient Safety Reporting System (PSRS) Safety Bulletins Coming Soon: PSRS, a NASA/VA collaboration independently operated by NASA to improve patient safety, has begun to receive patient safety reports from VA medical facilities at a rate that will allow the NASA PSRS office to issue de-identified findings.
  • MedWatch Reports: Information on the FDA’s safety information and adverse event reporting program, MedWatch.
  • View Point – Safety Hazards Around a Facility: The article discusses the importance of taking a second look at hazards around facilities, such as tree roots heaving the pavement (tripping hazards).
  • Sterilizing Medical Devices: On June 19, 2002, Advanced Sterilization Products issued a letter reminding its customers that all manufacturer instructions need to be followed when sterilizing and rinsing medical devices and products.
  • Safety Spotlight – Wrong ID Band: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • Ordering AEDs: VA facilities who order AEDs for their public facilities should be aware of the different types of AED models in the market.

May/June 2002

  • Total Care Bed System Notice: On Jan. 30, 2002, Hill-Rom issued a notice to 43 VA facilities that had purchased their Total Care Bed System beds between Nov. 1, 1997 and Oct. 5, 2001: two potential failure modes associated with the system’s bedside rails noted.
  • CPRS Patch Training Needed: A new national patch in April 2002 was released for the VistA Enrollment Application Systems software; concern expressed about the patch and suggestions offered.
  • Patient Safety Reporting System (PSRS) Roll-Out Completed: Developed by a partnership between VA and NASA, this article discusses roll-out of PSRS throughout all VA hospitals.
  • Patient Safety Awareness Week: Background on the nation’s first Patient Safety Awareness Week, celebrated March 10-16, 2002.
  • Facility Feedback – Distributing TIPS: Great ideas for improving distribution of TIPS in VA facilities.
  • Healthcare Failure Mode Effect Analysis (HFMEA™) Golden Nuggets: Tips or “golden nuggets” put together from lessons learned during HFMEA™ training sessions and by reviewing early HFMEA™ reports.
  • Safety Spotlight – Wrong Code Team Called: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • Spring is a Good Time to Review Elopement Risks: The long-awaited desire to be outdoors brings with it a heightened concern for patient elopements.

March/April 2002

  • Final Patient Safety Handbook Now on Web: On Jan. 30, 2002, the VHA National Patient Safety Improvement Handbook (VHA Handbook 1050.1) was officially adopted and the old 1051.1 rescinded.
  • Escorts Improving Patient Safety: Discusses development and implementation of an oxygen transport program with various components, including the Oxygen Patient Transport Communication Tool; escorts noted as an essential part of the team effort.
  • Safety Spotlight -- Patient Fall From Window: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • In Memoriam -- John Eisenberg, M.D., M.B.A: Thoughts on the death of John Eisenberg, M.D., M.B.A., after a lengthy illness. He was Director of the Agency for Healthcare Research and Quality.
  • Tips on Reducing Falls: During July 2001, 40 teams from VA and non-VA hospitals came together to begin a Collaborative Breakthrough Series on reducing falls and injuries in acute care and nursing home care settings. Collectively, the teams achieved a 45% reduction in serious injury rate over nine months.

January/February 2002

  • VA Patient Safety Program Receives National Recognition: VA’s patient safety program was nationally recognized last December when it was selected as a winner of the 2001 Innovations in American Government Award.
  • National Roll-Out of Aggregate RCAs: As of Jan.1, 2002, NCPS expanded aggregate RCA roll-out nationally. VHA facilities are now collecting data to be used for their aggregate RCAs.
  • Four Categories of Aggregate RCAs: VA has identified four categories of events that can be reviewed through a quarterly aggregate RCA: falls, missing patients, adverse medication events, and parasuicides (suicide attempts).
  • Safety Spotlight -- Transporting Patients With Oxygen Tanks: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • Learning Links -- The American Society of Anesthesiologists Web site -- the ASA: The site offers an in-depth investigation of closed anesthesia malpractice claims designed to identify major areas of loss, patterns of injury, and strategies for prevention.
  • Use of Statins: Baycol® (cerivastatin) was voluntarily withdrawn from the U.S. market because of a significantly higher number of cases of cerivastatin-associated rhabdomyolysis (skeletal muscle disease) compared to the other available statins.
  • Another Way to Look at Close Calls: At the VA, we define close calls as events or situations that could have resulted in an adverse event but did not, either by chance or through timely intervention.

October/November 2001

  • Patient Safety Summit Gives Attendees Plenty to Take Home: The VA/Quality Interagency Coordinating (QuIC) Task Force Summit on Effective Practices to Improve Patient Safety was held Sept. 5-7, 2001, Washington, D.C. Approximately 350 professionals attended; about two-thirds coming VA.
  • Safety Spotlight – Administering a Paralytic Agent: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • What is Healthcare Failure Modes and Effects Analysis™ (HFMEA™)?: Discusses HFMEA™ - a prospective risk analysis system developed by NCPS.
  • A Chance to Make a Difference … The Results: NCPS thanked those who submitted proposals for equipment and products that resulted from RCA recommendations and improved patient safety; recommendations reviewed.
  • Cognitive Aids Distributed: Discusses the first series of cognitive aids distributed by NCPS to VHA facilities throughout the country.

July/August 2001

  • Psychiatric Ward Screens: Some older facilities still have windows in locked psychiatric wards fitted with security screens; problems discussed.
  • SPOT Update: Discusses capabilities of SPOT, an RCA software product, that replaced the Microsoft Word RCA template.
  • Oral Medication Syringes: Close call discussed involving a nurse drawing up an oral liquid medication.
  • VA Salt Lake City Develops Community Collaborative Partnership: Discusses the VA Salt Lake City Health Care System’s work with community agencies to promote patient safety initiatives throughout the state.
  • Safety Spotlight – Surgical Towels: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • RCA Team Tips: Helpful hints for those involved in the RCA process.

May/June 2001

  • VA/ Quality Interagency Coordinating (QuIC) Task Force Patient Safety Summit: Under the auspices of QuIC, NCPS organized and convened the Summit on Effective Practices to Improve Patient Safety.
  • What is Quality Interagency Coordinating (QuIC) Task Force?: VA is one of 11 members of the federal government’s QuIC Task Force; discusses QuIC’s goals.
  • Facility Feedback – Unannounced JCAHO Survey: Wilkes-Barre VAMC discusses unannounced Joint Commission survey for Home Care/Durable Medical Equipment.
  • Dental X-Ray Film Warning: The FDA Public Health Notification warned of the potential for harmful lead exposure from dental film stored in tabletop containers lined with unpainted or coated lead.
  • Safety Spotlight – Failure to Obtain Consent for Surgery: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • Learning Links: Interesting articles and websites on patient safety issues.
  • Nitrogen or Nitrogen NF: Use of nitrogen to power operating room surgical equipment or dental office tools; difference between nitrogen medical-gas-grade and industrial, non-medical grade.

March/April 2001

  • Assessing the Environment of Care: Potential Electrical Shock: Many of VA hospital sleeping rooms have small televisions mounted on articulating arms serving each patient bed; discusses a close call.
  • Patient Safety Training Ideas: All full-time VHA employees are now required to receive 40 hours of continuing education training annually – of which 20 hours should be devoted to patient safety education.
  • O2 and CO2 Bottle Confusion: Discusses how the mishap occurred and ways to avoid reoccurrence.
  • Japanese Healthcare Organizations Visit NCPS: Japan had sent several delegations of healthcare officials to the United States on patient safety fact-finding tours; NCPS was visited.
  • New NCPS Logo: New Logo unveiled.
  • Safety Spotlight – MRI Near Miss: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • Learning Links: Interesting articles and websites on patient safety issues.

January/February 2001

  • Patient Safety Alerts – Where to Find Them on the Web: Where VA employees can find Patient Safety Alerts on the VA Intranet.
  • VA & NASA “Partners for Safety”: Discusses VA agreement with NASA, May 2000, to develop a Patient Safety Reporting System for the VA.
  • Facility Feedback – IG Visit, Joint RCA: Honolulu VAMROC and Tripler Army Medical Center form a joint process action team to conduct an aggregate RCA.
  • The Grapevine: Notes From the NCPS Staff – RCAs: Many facilities are not meeting the 45-day RCA completion time frame; recommendations on facilitating the process.
  • Safety Spotlight – CT Scan: Features teaching examples pulled from medical literature and similar RCAs that are applicable and of interest to the entire VHA health care system. The examples represent information taken from RCAs. Presented to spark discussion; does not represent NCPS policy.
  • Learning Links -- "Bad Human Factors Designs": Highlights a web site that is informative and innovative.
  • Salt Lake City Starts Reward Program: The Salt Lake City VAMC initiated several actions that substantially and positively impacted the patient safety program within their facility.
  • NCPS Rolls Out Improved Software: Discusses implementation of improved software for the RCA process and patient activities. The software, called SPOT, was then being used and evaluated in Florida VAMCs.