Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.

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.

The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.

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.   

The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.

Residents and trainees frequently report experiencing bullying and disrespectful behaviors in the workplace. This study explored the relationship between resident psychological safety, perceived organizational support, and humiliation. Results indicate resident perception of increased organizational support (e.g., help is available when they have a problem) reduces the negative impact of humiliation on their psychological safety.

Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.

… J Patient Saf … Dialysis is a common procedure that carries … and (4) the method for hemodialysis delivery. … Walton E,  Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: …

… 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 …

… 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 …

Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans Health Administration. The most frequent event type was medication administration error and the most frequent root cause was staff not following hospital policies or hospitals not having opioid-related policies. 

… J Patient Saf … This review expands upon previous work … to greater improvements.   … Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization … principles into practice: a rapid evidence review. J Patient Saf. Epub 2020 Sept 11. …

… J Patient Saf. … The goal of high-reliability organizations … 18 additional VHA sites. … Sculli  GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework …

Patient misidentification can lead to serious patient safety risks. Researchers used patient safety reports and root cause analyses (RCA) to characterize patient misidentification events in the Veterans Health Administration (VHA). The incidence of patient misidentification in inpatient and outpatient settings was similar and most commonly attributed to the absence of two unique patient identifiers. The authors identified three strategies to mitigate misidentification based on high-reliability principles: (1) develop policies for patient identification throughout the continuum of care, (2) develop policies to report and monitor patient misidentification measures, and (3) apply quality and process improvement tools to patient identification emphasizing use by front line staff.  

This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.

… PSN-ed!". Ann Emerg Med. Epub 2020 Aug 19. doi:  10.1016/j.annemergmed.2020.06.048   …

Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.

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

… 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: …