Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

Christina Soncrant; Peter D. Mills; Robin P Pendley Louis; William Gunnar

Study

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

November 17, 2021

Soncrant C, Mills PD, Pendley Louis RP, et al. J Patient Saf. 2021;17(8):e821-e828.

View more articles from the same authors.

Using data from the Veterans Health Administration National Center for Patient Safety, this retrospective study found that suicide and opioid overdose are the most serious healthcare-related adverse events affecting homeless veterans. Identified root causes include issues related to risk assessment for suicidal or overdose behaviors as well as poor interdisciplinary communication and coordination of care.

PubMed citation

Available at

Related Resources From the Same Author(s)

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

March 25, 2020

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.

September 23, 2020

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

November 24, 2021

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.

November 4, 2020

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Root cause analysis of ICU adverse events in the Veterans Health Administration.

August 30, 2017

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement.

June 1, 2022

Analysis of risk factors for patient safety events occurring in the emergency department.

October 7, 2020

Suicide and suicide attempts on hospital grounds and clinic areas.

August 11, 2021

A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients.

March 2, 2022

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.

October 24, 2018

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

April 6, 2022

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

September 29, 2021

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review.

November 10, 2021

Redeployment of health care workers in the COVID-19 pandemic: a qualitative study of health system leaders' strategies.

May 19, 2021

Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses.

June 9, 2021

The impact of adverse events on clinicians: what's in a name?

November 22, 2017

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.

June 16, 2021

Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.

September 2, 2020

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

June 29, 2022

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

The association between health care staff engagement and patient safety outcomes: a systematic review and meta-analysis.

February 3, 2021

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.

November 30, 2022

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review.

November 3, 2021

Race differences in reported "near miss" patient safety events in health care system high reliability organizations.

December 15, 2021

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Implementing high-reliability organization principles into practice: a rapid evidence review.

November 11, 2020

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods.

November 30, 2022

A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital.

April 27, 2022

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.

June 8, 2022

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Analysis of suicides reported as adverse events in psychiatry resulted in nine quality improvement initiatives.

July 21, 2021

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

September 7, 2022

Predictors of serious opioid-related adverse drug events in hospitalized patients.

July 8, 2020

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology.

May 19, 2021

Physician task load and the risk of burnout among US physicians in a national survey.

December 2, 2020

Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.

June 16, 2021

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings.

June 16, 2021

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

November 2, 2022

Patient falls in the operating room setting: an analysis of reported safety events.

May 11, 2022

Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals.

May 26, 2021

Adverse patient safety events during the COVID epidemic.

May 17, 2023

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

May 3, 2023

Teamwork before and during COVID-19: the good, the same, and the ugly….

August 24, 2022

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.

December 16, 2020

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

June 15, 2022

Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient medication safety.

September 21, 2022

Ethical issues in patient safety research: a systematic review of the literature.

September 9, 2015

A comparative study measuring the difference of healthcare workers reactions among those involved in a patent safety incident and healthcare professionals while working during COVID-19.

October 19, 2022

The patients' perspective: hematological cancer patients' experiences of adverse events as part of care.

August 18, 2021

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization.

October 21, 2020

The use of anatomical side markers in general radiology: a systematic review of the current literature.

August 26, 2020

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

November 17, 2021

Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study.

January 19, 2022

Applying decision science to the prioritization of healthcare-associated infection initiatives.

October 27, 2021

Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators.

July 28, 2021

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies.

May 25, 2022

Identification of adverse events in ground transport emergency medical services.

September 14, 2011

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

July 27, 2022

Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital.

June 24, 2020

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Disparities in adverse event reporting for hospitalized children.

August 3, 2022

The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesthesia department.

July 27, 2022

Creating psychological safety in interprofessional simulation for health professional learners: a scoping review of the barriers and enablers.

May 18, 2022

Post-discharge adverse events among African American and Caucasian patients of an urban community hospital.

July 15, 2020

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

November 25, 2020

The randomized AMBORA trial: impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment with new oral anticancer agents.

April 21, 2021

Critical care simulation education program during the COVID-19 pandemic.

November 10, 2021

Reporting of death in US Food and Drug Administration medical device adverse event reports in categories other than death.

August 11, 2021

Association between parent comfort with English and adverse events among hospitalized children.

November 11, 2020

Exploring changes in patient safety incidents during the COVID-19 pandemic in a Canadian regional hospital system: a retrospective time series analysis.

February 23, 2022

Data collection for adverse events reporting by US dental schools.

September 30, 2020

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Understanding patient and clinician reported nonroutine events in ambulatory surgery.

March 22, 2023

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation.

April 20, 2022

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.

March 17, 2021

Preventable morbidity and mortality among non-trauma emergency surgery patients: the role of personal performance and system flaws in adverse events.

May 12, 2021

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

October 12, 2022

Using community detection techniques to identify themes in COVID-19-related patient safety event reports.

December 7, 2022

'Doing the best we can': Registered nurses' experiences and perceptions of patient safety in intensive care during COVID-19.

September 7, 2022

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

August 10, 2022

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.

August 24, 2005

The impact of the built environment on patient falls in hospital rooms: an integrative review.

June 16, 2021

Bedside clinicians' perceptions on the contributing role of diagnostic errors in acutely ill patient presentation: a survey of academic and community practice.

March 16, 2022

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

April 29, 2015

Sharing lessons learned to prevent incorrect surgery.

November 21, 2012

Related Resources

Patient Safety Innovations

Suicide Prevention in an Emergency Department Population: ED-SAFE

April 24, 2024

Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic.

March 27, 2024

Interview

In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0

February 28, 2024

Voices from frontline nurses on care quality and patient safety during COVID-19: an application of the Donabedian Model.

November 1, 2023

Interview

In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

October 31, 2023

Perspectives on Safety

Addressing Workplace Violence and Creating a Safer Workplace

October 31, 2023

Bringing the equity lens to patient safety event reporting.

October 25, 2023

WebM&M Cases

Walking Out of a Hospital After Attempted Suicide

September 27, 2023

Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.

May 18, 2023

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

Addressing Medical Gaslighting to Improve Maternal Health—Together.

March 29, 2023

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

Coworker abuse in healthcare: voices of mistreated workers.

March 15, 2023

Improving clinician well-being and patient safety through human-centered design.

March 8, 2023

Misdiagnosis in the emergency department: time for a system solution.

February 8, 2023

National patient safety goal to improve health care equity.

February 8, 2023

Self-assessment and learning motivation in the second victim phenomenon.

February 1, 2023

Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals.

January 11, 2023

Changes in burnout and satisfaction with work-life integration in physicians over the first 2 years of the COVID-19 pandemic.

October 26, 2022

Improving diagnosis: adding context to cognition.

September 7, 2022

'Doing the best we can': Registered nurses' experiences and perceptions of patient safety in intensive care during COVID-19.

September 7, 2022

Tackling implicit bias in health care.

August 17, 2022

Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation.

June 29, 2022

Physicians' experiences with mistreatment and discrimination by patients, families, and visitors and association with burnout.

June 1, 2022

A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians.

May 25, 2022

Differences in hospitals' workplace violence incident reporting practices: a mixed methods study.

May 18, 2022

Survey shows room for improvement with three new best practices for hospitals.

May 18, 2022

Patient safety in home care: a multicenter cross-sectional study about medication errors and medication management of nurses.

May 18, 2022

See More About The Topic

Quality and Safety Professionals

Psychological and Social Complications

Epidemiology of Errors and Adverse Events

Quality Improvement Strategies

Education and Training

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

Suicide Prevention in an Emergency Department Population: ED-SAFE

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

Suicide Prevention in an Emergency Department Population: ED-SAFE

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site