A suicide attempt by a hospitalized patient is considered a never event. The majority of inpatient suicides occur in psychiatric units, but a prior Joint Commission sentinel event alert suggested that nearly 15% of attempts happen on medical wards. This study reviewed root cause analysis reports of suicide attempts on medical units in the Veterans Health Administration between 1999 and 2012. Fifty cases were identified and five represented completed suicides. Alcohol withdrawal was the most common reason for admission among patients who attempted suicide while hospitalized. The case reviews revealed communication failures, such as lack of discussion about suicide risks or mitigation plans during handoffs to other medical providers, as common contributors to these events. The authors recommend improved staff education, standardized communication for suicide risk, and protocols for appropriate management of suicidal patients. A prior article provided further implementation strategies for avoiding inpatient suicides.

Root cause analysis (RCA) has been a Joint Commission mandated tool for examining sentinel events since 1997. However, there is little objective data supporting its effectiveness. This cross-sectional study used the Veteran Affairs (VA) National Center for Patient Safety database to examine the relationship between RCA volume and Patient Safety Indicator (PSI) rates. Predictably, larger VA facilities performed more RCAs annually, and the number of RCAs was positively correlated with the development of strong actions intended to improve safety. Conversely, VA facilities that performed fewer than four RCAs per year had significantly higher rates of adverse events for three of the PSIs studied, all within the post-operative domain. The detailed steps for performing an RCA are described in an AHRQ WebM&M commentary.

This study used root cause analysis to identify systematic problems that resulted in incorrect assessment of suicide risk among veterans.

This study administered the Safety Attitudes Questionnaire and used its results as a proxy for improvements in safety following a medical team training intervention. The authors argue that the tool may better reflect changes in safety practices than tracking voluntary reports of adverse events.

The Department of Veterans Affairs Medical Team Training program is among the most effective in demonstrating meaningful outcomes. While similar teamwork training programs continue to emerge, many have increasingly focused on the adoption of specific tools such as debriefings in the surgical setting. This study describes a cardiopulmonary resuscitation (CPR) debriefing tool to guide postcode discussion and collect information on the code event. The authors share the practical development of the tool, its application, and lessons learned from implementation. They highlight how the tool and postcode discussions have guided identification and resolution of issues in the CPR code process, including code response times and satisfaction among team members.

The Veterans Health Administration has pioneered implementation of several innovative safety interventions, including teamwork training (using the Medical Team Training model) for surgical and intensive care unit staff. This report on the early effects of the teamwork training initiative found positive perceptions of the impact on teamwork, communication, efficiency, and patient safety. This preliminary study also provides examples of changes in participant behavior and clinical outcomes associated with implementation of the teamwork program. Failure to report these outcomes is a common limitation of teamwork training studies, as discussed in a recent systematic review.

Suicide in a hospitalized patient is considered a never event. The majority of inpatient suicide attempts occur in patients hospitalized on psychiatric units, and a prior study conducted in Veterans Affairs hospitals used root cause analysis to identify predisposing factors for suicide attempts. Based on those findings, in this study, the authors report on the development of a checklist to identify and minimize suicide hazards in mental health facilities. The checklist primarily focused on eliminating environmental hazards, such as anchor points for hanging attempts and materials that could be used as weapons. After implementation of the checklist, over three-quarters of potential hazards were removed. A case of a suicide attempt on a medical unit is discussed in an AHRQ WebM&M commentary.

Resident physicians in the United States currently work no more than 80 hours per week, according to regulations passed in 2003. By contrast, pilots are governed by much stricter regulations that limit their duty hours to approximately 1400 flying hours per year. This cost evaluation found that applying aviation industry work hour regulations to resident physicians would increase costs by more than $6 billion per year. Although a recent Institute of Medicine report recommended reducing the maximum shift length and increasing the duration between shifts—at an estimated cost of $1.7 billion—no reduction in the maximum number of hours worked per week was proposed. However, resident physicians in Europe will soon be restricted to working 48 hours per week, and a recent study of such a system found improved safety.

This review analyzes whether the available research on root cause analysis (RCA) substantiates its effectiveness as an improvement strategy.

This study assessed the value of AHRQ Patient Safety Indicator (PSI) rates as a measure of performance in Veterans Health Administration (VA) hospitals. Building on past efforts to study PSIs in the VA system, investigators concluded that PSIs are unreliable in comparing individual hospitals, largely due to the infrequent nature of most events. The authors advocate for use of PSIs in research settings rather than for purposes of measuring quality improvement interventions or rating the quality of individual providers.

A cognitive aid was developed to assist anesthesiologists in responding to emergency situations. Six months after dissemination of the aid, surveys revealed high levels of satisfaction with the tool.

The authors reviewed articles from the medical literature in which financial or economic analysis was an objective. They found inadequate evidence on the fiscal impact of patient safety interventions and suggest standard financial analysis techniques be used to support such initiatives.

The authors present a case study to illustrate system vulnerabilities related to computerized physician order entry (CPOE) use.

While the costs of medical error to patients are well appreciated, the direct costs to institutions, especially if error does not result in litigation, are less so. Even when errors increase length of stay or require additional interventions, these events usually represent billable charges and are not, from a purely economic standpoint, injurious to the institution. The authors, while acknowledging the ethical and societal imperatives to improve safety, outline the “business case” for patient safety investment, arguing that the long-term benefits to an organization’s reputation, efficiency, and medico-legal defensibility compensate for the sometimes high up-front costs of implementation.