AHRQ Patient Safety Network

The Collection > Department of Veterans Affairs (VA)

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (2)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (3)

•Medical Complications (3)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (7)

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Department of Veterans Affairs (VA)

Resource Types

•Award (1)

•Book/Report (3)

•Journal Article (42)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (1)

•Tools/Toolkit (1)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (7)

•Latent Errors (2)

Approach to Improving Safety

•Quality Improvement Strategies (7)

•Legal and Policy Approaches (4)

•Error Reporting and Analysis (24)

•Communication Improvement (6)

•Human Factors Engineering (7)

•Teamwork (7)

•Specialization of Care (1)

•Logistical Approaches (9)

•Culture of Safety (21)

•Technologic Approaches (6)

•Education and Training (14)

Clinical Areas

•Medicine (29)

•Nursing (5)

Target Audience

•Health Care Providers (30)

•Health Care Executives and Administrators (37)

•Non-Health Care Professionals (15)

Setting of Care

•Hospitals (48)

•Ambulatory Care (1)

1 - 20 of 52

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STUDY

An overview of patient safety climate in the VA.

Hartmann CW, Rosen AK, Meterko M, et al. Health Serv Res. 2008;43:1263-1284.

STUDY

Recruitment of hospitals for a safety climate study: facilitators and barriers.

Rosen AK, Gaba DM, Meterko M, et al. Jt Comm J Qual Patient Saf. 2008;34:275-284.

MULTI-USE WEBSITE

National Center for Patient Safety (NCPS).

Department of Veterans Affairs (VA), PO Box 486, Ann Arbor, MI 48106-0486.

TOOLKIT

Healthcare Failure Mode and Effect Analysis.

VA National Center for Patient Safety.

STUDY

Using patient safety indicators to estimate the impact of potential adverse events on outcomes.

Rivard PE, Luther SL, Christiansen CL, et al. Med Care Res Rev. 2008;65:67-87.

STUDY

Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program.

Carney BT, West P, Neily JB, Mills PD, Bagian JP. Am J Med Qual. 2011;26:480-484.

STUDY

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. Am J Surg. 2009;198:70-75.

BOOK/REPORT

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

Washington, DC: VA Office of Inspector General; April 20, 2012. Report No. 12-00956-159.

STUDY

Association between implementation of a medical team training program and surgical morbidity.

Young-Xu Y, Neily J, Mills PD, et al. Arch Surg. 2011;146:1368-1373.

COMMENTARY

Using the rapid response system to provide better oversight of patient care processes.

Moore MS, Howard SK, Lighthall G. Jt Comm J Qual Patient Saf. 2007;33:695-698.

STUDY

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.

DeRosier J, Stalhandske E, Bagian JP, Nudell T. Jt Comm J Qual Improv. 2002;28:248-267, 209.

COMMENTARY

Reducing diagnostic error through medical home-based primary care reform.

Singh H, Graber M. JAMA. 2010;304:463-464.

STUDY

Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.

Volpp KG, Rosen AK, Rosenbaum PR, et al. JAMA. 2007;298:975-983.

STUDY

Developing and testing a tool to measure nurse/physician communication in the intensive care unit.

Manojlovich M, Saint S, Forman J, Fletcher CE, Keith R, Krein S. J Patient Saf. 2011;7:72-76.

STUDY

Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods.

Patterson ES, Doebbeling BN, Fung CH, Militello L, Anders S, Asch SM. J Biomed Inform. 2005;38:189-199.

COMMENTARY

Patient safety: lessons learned.

Bagian JP. Pediatr Radiol. 2006;36:287-290.

BOOK/REPORT

VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities.

US Government Accountability Office. Washington, DC: US Government Accountability Office; 2004. Publication GAO-05-83.

STUDY

Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer.

Hayward RA, Hofer TP. JAMA. 2001;286:415-420.

STUDY

What context features might be important determinants of the effectiveness of patient safety practice interventions?

Taylor SL, Dy S, Foy R, et al. BMJ Qual Saf. 2011;20:611-617.

BOOK/REPORT

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

Washington, DC: United States Government Accountability Office; August 2012. Publication GAO-12-827R.

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