Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

… J Patient Saf … The COVID-19 pandemic dramatically changed …

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   

… J Patient Saf … The first surge of the COVID-19 pandemic … of safety issues are described. … Charles MA, Yackel EE, Mills PD, et al. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. J Patient Saf. …

… J Patient Saf … Delays in diagnosis and treatment can lead to … challenges, and equipment or supply issues. … Politi RE, Mills PD, Zubkoff L, et al. Delays in diagnosis, treatment, … taken, and recommendations for healthcare improvement. J Patient Saf. Epub 2022 Apr 30. …

… J Patient Saf … Dialysis is a common procedure that carries … the method for hemodialysis delivery. … Walton E,  Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: … analysis reports in the Veterans Health Administration. J Patient Saf. Epub 2021 Sep 28. …

… J Patient Saf … Using data from the Veterans Health … communication and coordination of care. … Soncrant C, Mills PD, Pendley Louis RP, et al. Review of reported adverse … veteran population in the Veterans Health Administration. J Patient Saf. Epub 2021 Aug 19. …

… J Patient Saf … Researchers reviewed 15 years of root cause … root causes of attempted and completed patient suicides. … Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J Patient Saf. 2021;17(5):e423-e428. …

… Jt Comm J Qual Patient Saf … Opioid misuse and overdose continues to … having opioid-related policies.  … Norris B, Soncrant C, Mills PD, et al. Root cause analysis of adverse events … overdoses in the Veterans Health Administration. Jt Comm J Qual Patient Saf. Epub 2021 May 20. …

… monitoring, control of firearms, and close observation. … Mills PD, Soncrant C, Gunnar W. Retrospective analysis of …

… J Patient Saf … In this retrospective review of root cause … items were associated with the most harm. … Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events …

… J Patient Saf … This retrospective cohort study used root … (11%) or lacking standardization (10%). … Gill S, Mills PD, Watts BV, et al. A review of adverse event reports … departments in the Veterans Health Administration. J Patient Saf. 2020. Epub 2020 Feb 23. doi: …

Root cause analysis is a fundamental approach to understanding how failures occur, but some have questioned its effectiveness in health care. This review highlights alternative approaches to incident analysis that address some of the concerns with root cause analysis, such as time commitment and lack of follow up.

The authors describe the results of a survey of anesthesiology chiefs designed to understand their perceptions of the Veterans Health Administration efforts surrounding the lessons learned process for adverse events occurring in anesthesia. Of participants who had been aware of lessons learned, 90% shared them with staff and 75% described changing or reinforcing safety behaviors.

The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.

This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.

Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings. This quality improvement project applied the method to patient falls in Veterans Health Administration operating rooms and developed recommendations to guide improvement. Areas of focus included team communication, restraint use, and staff education. An Annual Perspective provides insights regarding how to enhance root cause analysis to help investigate incidents and improve care.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … A number of studies have shown that …

… Journal of patient safety … J Patient Saf … This commentary describes the deployment of a …

This study examined reports stemming from retained guidewires, a never event, across Veterans Affairs hospitals. Common causes included inexperience, lack of checklists, and insufficient standardization. The authors recommend applying human factors approaches to prevent this adverse event.