VHA National Center for Patient Safety
NCPS Public Affairs Officer Retires
Joseph Murphy, M.S., APR, retires after 12 years at NCPS and 22 years of federal service.
Redesigned NCPS Internet Site Proven Effective
- One year after the launch of the new site, more than 168,000 users visited it.
- Nearly 50,00 documents were down-loaded by professionals and Veterans, indicating the relevance and quality of the information offered.
Prescription Labeling Format Implimented
- All VA Medical Centers implemented a new patient-centric label format.
- The goal of the initiative, begun in 2011, was to determine how best to serve the VA's approximately 4.4 million pharmacy users through redesign of labels affixed to nearly 122 million prescriptions despensed yearly.
New Toolkit Added to the Professional Section of the NCPS Internet site
- "A Toollkit: Patients at Risk for Wandering" added.
- Includes a variety of interventions to prevent patients from wandering or become missing from VA facilities and grounds.
Redesigned NCPS Internet Site Launched
- Based on a detailed usablilty study and a new, flexable VA website format, the customer-focused site offers Veterans and professionals numerous opportunities to learn more about VA patient safety.
Millions of Veterans use new Prescription Labeling Format
- As of December 2013, 5 million Veterans received prescriptions using the new patient-centric labeling format.
- Roll-out began in February 2013.
Patient Safety Training for Biomedical Engineers Launched
- NCPS conducted the first "Patient Safety Boot Camp" for VA's Technical Career Field Biomedical Engineers.
- The training fostered collaboration between biomedical engineering and patient safety, meant to further promote a culture of safety with VHA facilities.
National Prescription Label Approved
- Based on a 2011 NCPS study and trial completed in 2012, a new standardized patient-centric prescription label was approved for VHA-wide roll-out during 2013.
Accreditation Council for Graduate Medical Education (ACGME)
- NCPS participated on the ACGME Clinical Learning Environment Review Committee to help ensure the next generation of physicians learn and acquiring patient safety skills.
Chief Resident in Quality and Safety Launched
- Developed in association with the VA Office of Academic Affiliations and The Dartmouth Institute
- Chief Residents from 21 VA Medical Centers (with university affiliation) are participating in a patient safety boot camp, two-way interactive video conferences, and quality improvement projects.
National Prescription Labeling Study Completed
The study, "Improving Veteran health-literacy and safety through implementation of a novel, evidence-based, patient-centered outpatient prescription label," evaluated Veterans' understanding of prescription labels, in an effort to develop a single standardized prescription label for use across the VA.
- The study's goal was to determine how best to serve the VA's 4.4 million pharmacy users through the redesign of labels affixed to nearly 122 million prescriptions dispensed each year.
- One of the findings indicated that 64 percent of Veterans and 62 percent of VA pharmacy staff preferred a standardized, patient-centric prescription label.
- Implementation has been approved by the VA Medical Advisory Committee.
Medical Team Training
A VA study, "Association between implementation of a medical team training program and surgical morbidity," was published by The Archives of Surgery.
- Analyzed data from 119,383 procedures at 74 VA facilities. The program had been implemented at 42 of the facilities; the other 32 facilities served as a control group.
- After adjusting for surgical risk, a decrease of 15 percent in morbidity rate was found for facilities in the MTT program; a decrease of 10 percent for those not yet in the program.
- While the risk of surgical complications declined in both groups, the decline was 20 percent steeper in the MTT group.
Medical Team Training
A VA study, "Incorrect Surgical Procedures Within and Outside of the Operating Room," published online by The Archives of Surgery, indicated a continued overall decrease in the number and severity of wrong site surgeries in the VA.
- Two hundred and thirty-seven incidents were reviewed, which occurred from mid-2006 to 2009.
- The rate of reported adverse events decreased from 3.21 to 2.4 per month.
- Reported close calls increased from 1.97 to 3.24 per month, in which a problem was caught before any harm could come to a patient.
- Robin Hemphill, M.D., became the VHA's Deputy Chief Patient Safety Officer and Director, National Center for Patient Safety.
First use of Simulation-Based Training in Patient Safety Curriculum Program
- Simulation-based teamwork training, using observational experiential learning, presented to an audience of 105 residents and faculty at the Greater Los Angeles VA Medical.
NCPS Founding Director Retires
- James P. Bagian, M.D., P.E., was chosen as the first and founding director of NCPS in 1998 and the first VA Chief Patient Safety Officer.
Medical Team Training
A VA study, “Association between implementation of a medical team training program and surgical mortality,” was published in the Journal of the American Medical Association.
- The study found an almost 50 percent greater decrease in the annual surgical mortality rate in groups trained in MTT methods, as opposed to untrained groups.
- It was also noted that the longer MTT had been practiced at a medical facility, the greater the decrease in mortality.
Patient Safety Curriculum Program
- Led the development of a comprehensive simulation-based training program in support of VA's "Ensuring Correct Surgery and Invasive Procedures" directive.
- Program staff worked with NCPS leadership and members of the NCPS Medical Team Training and Daily Plan® programs, as well as with those from VA Central Office, VA Simulation Learning Education and Research Network, VA Employee Education System, and the directors of VA's surgery and nursing programs.
Medication Label Literacy Project
- VA research grant received: "Innovation Funding for the Advancement of a Patient-Centered Care Culture" initiative.
- Veterans will be directly involved in the effort to develop a single standardized prescription label for use within the VA.
- Research will be conducted at 10 VA Medical Centers throughout fiscal year 2010 and 2011.
Cornerstone Recognition Program
- One hundred and twenty-two facilities received awards in 2009, indicating that nearly 80 percent of all VA facilities have improved their patient safety programs.
- RCA timeliness has improved dramatically: 95.7 percent were completed within 45 days in fiscal year 2009; up from just 44.5 percent in fiscal year 2006.
One of the methods for determining whether or not an RCA has been effective is through the concept of "strong strings," defined as any action with stronger or intermediate strength, a quantifiable outcome measure, and management concurrence.
- RCAs with strong strings have improved dramatically: 74 percent in fiscal year 2009; up from just 41.7 percent in fiscal year 2006.
- Facilities with at least one strong string in every RCA have improved dramatically: 21.6 percent in fiscal year 2009; up from just 6.5 percent in fiscal year 2006.
VHA Product Recall Office
Since NCPS implemented the VHA recall program in November 2008, significant improvement as been shown in on-time completion of Class 1 recalls.
- In December 2009, compliance rose to 92.4 percent; up from just 65.9 percent in December 2008.
- Internal multimedia site launched and first podcasts (completed in the VA) and videos placed online.
Medical Team Training Phase II Launched
- Phase II training areas include: interventional radiology, cardiac catheterization laboratory, medical/surgical floors, emergency rooms, medical intensive care units, primary care, and mental health.
Medical Team Training Phase I Completed
- One hundred and twenty-nine VHA facilities participated and more than 10,000 staff were trained, resulting in improved patient surgical outcomes and higher staff morale.
- Cornerstone of Phase I: implementation of pre-operative briefings and post-operative debriefings, guided by a checklist.
Patient Safety Initiative
- In the fourth year of innovative micro-grant allocations, 18 new projects were funded; nearly 80 have been funded since the program began.
Cornerstone Recognition Program
- Seventy-one medical facilities received awards.
VHA Product Recall Directive 2008-080 Implemented
- NCPS Product Recall Officer tasked to manage recall of all medical devices and products initiated by manufactures or the FDA that are applicable to VHA.
Adverse Drug Event (ADE) Reporting and Monitoring directive implemented (VHA Directive 2008-059)
- Establishes the process for reporting, monitoring, and surveillance of ADEs.
Patient Safety Improvement Corps Concluded Final Training Sessions
- Additional training requested by Health and Human Services (HHS) completed for 22 teams from a number of states, as well as Puerto Rico. The teams were comprised of state health officials and members of their selected hospital partners.
- This landmark interagency agreement between HHS and VA was funded by the Agency for Healthcare Research and Quality. Begun in 2003, participants included more than 300 health care professionals from 210 organizations
The Daily Plan® Pilot Program Completed
- The plan was piloted for two weeks at five volunteer VA medical centers’ medical-surgical units. The first pilot was begun in August 2007.
- This initiative enhances patient safety by involving patients in their care: A single document is provided to them that outlines what can be expected on a specific day of hospitalization.
NCPS Product Recall Office Designated
- Tasked to manage recalls of all medical devices and products initiated by manufactures or the FDA that are applicable to VHA.
Cornerstone Recognition Program Launched
A recognition program initiated to enhance the RCA process and recognize the good work done for patient safety at the facility level.
- Recognition criteria focus on timeliness and strength of actions, as well as on reporting back on the impact of actions taken.
- Facilities can earn bronze, silver or gold awards, based on the number of RCAs completed and the quality of the RCAs.
- Six Patient Safety Centers of Inquiry funded.
Patient Safety Fellowship Program Launched
- Co-sponsored by the VA Office of Academic Affiliations; eleven fellows selected for the initial program.
Patient Safety Initiative Funded 18 Proposals Developed in Fiscal Year 2007
Patient Safety Design Challenge
- Four teams were recognized for taking a creative approach to design during the VA National Patient Safety Managers Conference.
Patient Safety Improvement Corps
- NCPS completed patient safety training for Improvement Corps participants from all 50 states and the District of Columbia, a three-year project.
Automated Patient Safety Assessment Tool Launched
Patient Safety Initiative funded 26 Proposals Developed in Fiscal Year 2006
Patient Safety Initiative Announced
- The goal of PSI is to stimulate creative approaches to complex patient safety issues among VA patient safety officers and managers.
Prevention of Retained Surgical Items Directive Issued
NCPS staff Member Received a Cheers Award From the Institute for Safe Medication Practices
- The award honors those who have set a standard of excellence in the prevention of medication errors and adverse drug events.
Patient Safety Design Challenge Announced
- The voluntary program allows patient safety managers to create a positive impact on design standards VA-wide.
Airway Management Initiative Launched
Joint Commission Resources Published “Using Human Factors Engineering to Improve Patient Safety”
- NCPS staff member, editor.
Second Patient Safety Culture Survey Conducted
BETA Test for Automated Patient Safety Assessment Tool Conducted
NCPS Director Received a Patient Safety Award
- James P. Bagian, PE, MD.
- Presented by the Centers for Disease Control and Prevention, in partnership with the Institute for Quality in Laboratory Medicine.
- Acknowledged for “pioneering” work in patient safety and “contributions to improvements in healthcare.”
Falls Data Collection Project Launched
NCPS Updated the American Heart Association “Emergency Cardiovascular Care Handbook for Code Carts”
Hand Hygiene Directive Issued; Dedicated Web Page Offered
NCPS Program Manager Selected as a Distinguished Alumnus by Wayne State University’s Pharmacy Alumni Association Affiliate Board of Directors
- Recognized for significant and sustained contributions to her field.
First Medical Team Training Session Conducted VA Medical Center Houston, Texas
Falls Toolkit Launched
- Multimedia kit aimed at reducing falls among elderly patients.
Six Sigma/3M Hand Hygiene Project Completed
NCPS Program Manager Joe DeRosier Earned Bronze Telly Award for Outstanding Achievement in Video Production, Developing the “Safe Use of Oxygen” Training Video
NCPS Conducted Patient Safety Workshops for Senior Leadership
VHA Guidelines on Hand Hygiene Requirements Issued
NCPS Director Honored with Career Achievement
- James P. Bagian, PE, MD.
- The Partnership for Public Service honored the NCPS Director with a Service to America Medal.
The National Patient Safety Improvement Corps Launched
- VHA/NCPS embarked upon a three-year interagency agreement with the Department of Health and Human Services’ Agency for Healthcare Research and Quality to launch a national “Patient Safety Improvement Corps.”
- NCPS tasked to formulate, manage and implement a multifaceted training program for state health officials and their selected hospital partners.
Medical Team Training Pilot-Tested
- Grounded in two decades of aviation safety and human factors engineering studies, the initiative will be used to evaluate the effectiveness of team training in high-risk environments, such as the operating room.
Patient Safety Curriculum Pilot Begun
- Pilot testing of faculty development workshops for physician teachers began; actively solicited academic affiliate buy-in and partnership opportunities.
Patient Safety Assessment Tool Launched
- The tool allows patient safety managers to complete a detailed assessment of the status of their facility’s program and was pilot tested and evaluated by four networks.
- Began training of VA facility directors, patient safety officers, and patient safety managers in its use.
Ensuring Correct Surgery Directive Implemented
- The directive offers a simple, straight forward five-step procedure to avoid adverse surgical events.
- A collection of cognitive aids were created to support providers and patients (e.g., video, brochure, poster, Inter- and Intranet Web sites).
U.S. Medicine Honored Director with Frank Brown Berry Prize
- James P. Bagian, PE, MD.
- Awarded the prize for conceiving and establishing a comprehensive patient safety system that emphasizes prevention of adverse medical events, rather than punishment of providers, through the reporting and analysis of adverse events and close calls.
NCPS staff member launched Patient Safety Curriculum Initiative
- The initiative continues development of a patient safety curriculum for medical students, residents, and other healthcare professionals derived from six years of work with residents at Michigan State University and nursing students at Western Michigan University.
- Several physicians and patient safety personnel from VA medical centers and affiliated universities volunteered to assist with the development and testing of the patient safety curriculum pilot.
Patient Safety Information Systems Director Earned a Becton Dickinson Career Achievement Award
- Given to “encourage and support further contributions by healthcare professionals in the improvement of medical devices, instruments, or systems. The intent is to identify, recognize, and encourage outstanding achievement(s) by a promising healthcare professional.”
Tool Kit for Improving Patient Safety Made Available
- Created in partnership with the American Hospital Association
- The toolkit helps hospitals prioritize and evaluate aspects of care delivery that may be at high-risk for causing patient harm or have been associated with an adverse event or close call.
NCPS Awarded the John M. Eisenberg Patient Safety Award for System Innovation
- Recognized for “developing and implementing a systems approach to error reduction within the VHA’s 163 healthcare facilities.”
- Presented for projects or initiatives involving successful system changes or interventions that make the environment of care safer.
NCPS selected for 2001 Innovations in American Government Award
- One of five winners for this national honor; the only federal program selected from more than 1,200 applicants.
- NCPS was cited for preventing and reducing adverse medical events by addressing systemic vulnerabilities.
VA/Quality Interagency Coordination Task Force (QuIC) Summit on Effective Practices to Improve Patient Safety Convened
- Organized by NCPS to improve patient safety.
- Presented information for immediate use by patient safety managers.
- Attended by approximately 350 professionals (VA and non-VA).
Healthcare Failure Mode and Effect AnalysisSM Launched
- Included training program and cognitive aids.
NCPS Director Honored by the American Medical Association
- James P. Bagian, PE, MD, received the AMA’s Dr. Nathan Davis Award.
- The award, named for the founding father of the AMA, recognizes elected and career officials in federal, state, or municipal service whose outstanding contributions have promoted the art and science of medicine and the betterment of public health.
Patient Safety Reporting System (PSRS) Pilot-Tested
- First pilot test with Veterans Integrated Service Network (VISN) 22.
- Second pilot test follows in December 2001 with VISN 16.
Roll-Out of New Root Cause Analysis Software (The Patient Safety Information System, Nicknamed “SPOT”)
- SPOT further automates the VA patient safety reporting analysis process and corrective action measures.
- Features include enhanced analysis capabilities at the facility level; secure electronic submission of RCAs from facilities to NCPS; tools to follow up, track, and document corrective actions and outcome measurements; and tools to develop automated flow charts.
Comprehensive Adverse Event and Close Call Analysis Program Launched
- Spanning 10 months, NCPS conducted training on safety improvement methods to more than 700 personnel who had been selected to lead patient safety programs at VA facilities.
VA Contracted with NASA to Create Patient Safety Reporting System (PSRS)
- PSRS launched as an external, voluntary, and confidential program.
- Developed to complement an internal comprehensive adverse event and close call analysis program.
- Acts as a “safety valve” to help ensure that otherwise unknowable vulnerabilities are identified.
First Patient Safety Cultural Survey Conducted
Roll-Out of Adverse Event and Close Call Analysis Program
- After pilot testing with VISNs 8 and 22, NCPS begins roll-out of the program throughout VA medical system.
- VA and healthcare professionals from other public and private sector healthcare entities, nationally and internationally, begin attending NCPS-sponsored training on a regular basis.
Pilot Testing of Adverse Event and Close Call Analysis Program
- First pilot test conducted at VISN 8.
- Second pilot test follows in February 2000 at VISN 22.
NCPS is Established
- James P. Bagian, PE, MD, begins work as the first NCPS Director.
VA National Center for Patient Safety is Announced