The VA GAPS Center: Stories.

Toolkit

The VA GAPS Center: Stories.

March 6, 2005

The VA Getting at Patient Safety (GAPS) Center; The VA GAPS Center.

Stories from a variety of disciplines are provided to illustrate fundamental patient safety concepts. This site presents a narrative with visual and text-based aids, presentation slides, a human factors explanation of the concept, discussion questions, and links to additional resources.

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PEXiS.

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Patient Safety Huddle.

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SaferCare Texas

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Project Red (Re-Engineered Discharge).

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Patient Safety.

October 29, 2008

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

May 24, 2023

Patient Deaths at Arbour Health Systems—Westwood Lodge Hospital and Pembroke Hospital.

March 21, 2018

On the CUSP: Stop HAI.

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Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.

January 25, 2006

Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process.

November 8, 2017

Patient Safety in Ambulatory Settings: Technical Brief.

December 16, 2015

Promoting Patient Safety: An Ethical Basis for Policy Deliberation.

March 6, 2005

Inpatient Quality Indicators.

March 6, 2005

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.

May 12, 2021

Coronavirus Commission for Safety and Quality in Nursing Homes.

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VA Interprofessional Fellowship Program in Patient Safety.

November 22, 2006

Connecticut Center for Patient Safety.

June 20, 2007

Tennessee Center for Patient Safety.

September 14, 2011

TIPS (Topics in Patient Safety).

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National Center for Patient Safety Falls Toolkit 2004.

March 27, 2005

Healthcare Failure Mode and Effect Analysis.

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Institution of just culture physician peer review in an academic medical center.

October 13, 2021

Diagnostic Errors in Primary Care.

July 27, 2021

Annual Communication, Apology, and Resolution (CARe) Forum.

August 10, 2023

Massachusetts Alliance for Communication and Resolution Following Medical Injury.

March 5, 2014

Ensuring Correct Surgery.

February 8, 2006

AMC PSO Resource Center.

July 27, 2021

Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions.

May 3, 2006

Patient safety and mental health-a growing quality gap in Canada.

October 6, 2021

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

November 17, 2021

Duplicate medication order errors: safety gaps and recommendations for improvement.

October 12, 2022

Peer Support Toolkit.

September 29, 2021

North Carolina Center for Hospital Quality and Patient Safety.

May 17, 2006

Patient Safety Curriculum.

December 10, 2008

Take Charge: 5 Steps to Safer Healthcare.

April 21, 2021

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

February 12, 2020

The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.

June 19, 2019

Voices from the Frontlines of Health Care Safety.

May 31, 2023

The impact of TeamSTEPPS training on obstetric team attitudes and outcomes on the labor and delivery unit of a regional perinatal center.

February 1, 2023

Factors associated with workplace violence among healthcare workers in an academic medical center.

April 27, 2022

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

June 15, 2016

Bias and racism teaching rounds at an academic medical center.

December 23, 2020

Applying human factors engineering to address the telemetry alarm problem in a large medical center.

August 11, 2021

Emerging Topics in Quality Improvement.

February 14, 2023 - February 14, 2023

Nurses and doctors sick with COVID feel pressured to get back to work.

August 26, 2020

Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed at trainees at an academic medical center.

December 21, 2022

People for Patient Safety.

June 12, 2023 - June 12, 2023

Improving Patient Safety: The Intersection of Safety Culture, Clinician and Staff Support, and Patient Safety Organizations.

October 28, 2015

Getting the whole story: integrating patient complaints and staff reports of unsafe care.

July 28, 2021

Medmarx Data Report: A Chartbook of Medication-Error Findings from the Perioperative Settings from 1998-2005.

March 21, 2007

Bridging the gap between culture and safety in a critical care context: the role of work debate spaces.

August 26, 2020

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center.

August 12, 2020

How to Talk About Patient Safety.

April 3, 2019

MEDMARX Data Report: A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine's Call to Action (2003-2006 Findings and Trends 2002-2006).

February 13, 2008

Med List.

April 4, 2007

MEDMARX 5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999-2003.

March 27, 2005

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

Quality improvement for patient safety: project-level versus program-level learning.

February 22, 2012

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.

August 26, 2020

Evidence-based Recommendations for Best Practices in Weight Loss Surgery.

March 27, 2005

Institute for Patient- and Family- Centered Care.

June 16, 2010

Health Information Technology Leadership Panel: Final Report.

May 25, 2005

Stay Connected: FAQs about Small-Bore Connectors and Tubing Misconnections.

November 6, 2013

Frontline assessments of healthcare culture: Safety Attitudes Questionnaire norms and psychometric properties.

March 27, 2005

Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit.

December 7, 2011

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Get the Medications Right Institute.

August 7, 2019

Teamwork Toolkit.

July 24, 2019

Impact Wellbeing.

November 29, 2023

Implementation of patient safety structures and processes in the patient-centered medical home.

June 30, 2021

Strategically Advancing Patient and Family Advisory Councils in New York State Hospitals.

September 12, 2018

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes.

November 12, 2014

Narrowing the mindware gap in medicine.

July 20, 2022

Accountability: Patient Safety and Policy Reform.

March 6, 2005

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness.

March 27, 2005

Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab.

June 8, 2022

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

March 8, 2023

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Bad things can happen: are medical students aware of patient centered care and safety?

January 25, 2023

Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19.

December 16, 2020

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

June 4, 2014

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

June 13, 2012

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

The Anatomy of Medical Error: Preventing Harm with People-Based Patient Safety.

October 25, 2006

Association for Professionals in Infection Control and Epidemiology.

July 26, 2006

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

November 29, 2023

Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications.

March 5, 2014

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home: a qualitative descriptive study.

July 10, 2019

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives.

February 15, 2023

Behavioral & Mental Health Toolbox.

March 7, 2018

Related Resources

Hospital Harm Project.

October 31, 2023

Maryland Hospital Patient Safety Program Annual Report.

September 28, 2023

TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety.

July 23, 2023

Action Planning Tool for the AHRQ Surveys on Patient Safety Culture.

December 5, 2022

Patient Safety Incident Response Framework.

August 31, 2022

Nursing Home Survey on Patient Safety Culture.

August 31, 2022

Hospital Performance Report.

October 28, 2021

Medical Office Survey on Patient Safety Culture.

September 1, 2021

"Talk About Your Medicines" Month.

April 4, 2021

Knowledge, attitudes, and expectations of medical staff toward medical error management policies in humanitarian medicine: a qualitative study.

February 10, 2021

Circle Up for COVID-19 Training.

May 13, 2020

Sepsis Smart.

October 30, 2019

CUSP Toolkit.

September 26, 2019

Teamwork Toolkit.

July 24, 2019

Patient Safety Learning.

July 17, 2019

The Canadian Quality and Patient Safety Framework for Health and Social Services.

May 22, 2019

Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

May 1, 2019

The Kentucky Institute for Patient Safety and Quality.

November 7, 2018

Behavioral & Mental Health Toolbox.

March 7, 2018

RxAwareness.

October 25, 2017

Health Literacy Tools for Providers of Medication Therapy Management.

August 16, 2017

Turn the Tide Rx.

November 23, 2016

Nursing Home Antimicrobial Stewardship Guide.

November 9, 2016

Giving voice to quality and safety matters at board level: a qualitative study of the experiences of executive nurses working in England and Wales.

August 24, 2016

Eliminating Harm, Improving Patient Care: A Trustee Guide. 2018 Update.

September 9, 2015

Patient Safety Tool Kit.

June 24, 2015

ANA CAUTI Prevention Tool.

April 8, 2015

AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.

February 4, 2015

Evaluating ambulatory practice safety: the PROMISES Project administrators and practice staff surveys.

December 17, 2014

Betsy Lehman Center for Patient Safety.

December 10, 2014

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