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.   

Simulation training is used to improve technical and nontechnical skills among healthcare teams. This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on code response, teamwork, communication and comfort during intraoperative resuscitations. After simulation training, researchers noted improvements in technical skills of individuals and teams (e.g., CPR-related technical skills).

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.

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 Interprof Care … Health profession schools are increasingly … learners: a scoping review of the barriers and enablers. J Interprof Care. doi: 10.1080/13561820.2022.2052269 …

Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.

… 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. …

Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide attempts on Veterans Health Administration (VHA) grounds. Forty-seven suicides or suicide attempts were identified, and primary root causes included communication breakdown and a need for improved suicide interventions. The paper includes recommended actions to address the root causes of attempted and completed patient suicides.

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 Eval Clin Pract … Many organizations have implemented … interventions. … Janes G, Harrison R, Johnson J, et al. Multiple meanings of resilience: Health … designed to help them prepare for coping with error. J Eval Clin Pract. Epub 2021 Mar 6. doi: 10.1111/jep.13555. …

… J Patient Saf … The delivery of safe, reliable, … an effective way to  enhance  patient safety.   … Janes G, Mills T, Budworth L, et al. The association between health … safety outcomes: a systematic review and meta-analysis. J Patient Saf. Epub 2021 Jan 12.    …

The goal of high-reliability organizations is to operate in high-hazard domains with consistently safe conditions, but implementation of high reliability has yet to be universally employed in health care. This article describes the implementation of a high-reliability hospital framework on patient safety culture and clinical outcomes at one VHA medical center. Framework components included an annual patient safety assessment, annual safety culture survey, annual root cause analysis (RCA) training, leadership walk arounds, and just culture training. Three years after implementation, patient safety culture and event reporting rates improved, and the medical center experienced significant improvements in mortality and complication rates compared to other VHA hospitals. Based on these results, the framework will be implemented across 18 additional VHA sites.

Developed in the field of aviation, crew resource management (CRM) is used to teach teamwork and effective communication and has been used extensively in patient safety improvement efforts. This commentary describes four New York metropolitan area emergency departments’ experience applying (CRM) principles at an organizational level in responding to the current COVID-19 pandemic as well as future crises.

This study examined the prevalence and risk factors for COVID-19 infection among frontline healthcare personnel who work with COVID-19 patients. Serum specimens were collected from a convenience sample of 3,248 frontline personnel between April 3 and June 19, 2020.  Six percent (6%) tested positive for SARS-CoV-2 antibodies; a high proportion of these individuals did not suspect that they had been previously infected. This study highlights the role that asymptomatic COVID-19 infections play and authors suggest that enhanced screening and universal use of face coverings in hospitals are two strategies to reduce COVID-19 transmissions in healthcare settings.

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.

The authors reviewed studies using qualitative and quantitative methods to describe nursing workarounds related to the electronic health record (EHR) in direct care activities. Workarounds generally fit into three categories – omission of process steps, steps performed out of sequence, and unauthorized process steps. Probable causes for workarounds were identified, including organizational- (e.g., knowledge deficits, non-formulary orders), environmental-, patient- (e.g., barcode/ID not accessible), task- (e.g., insufficient time), and usability-related factors (e.g., multiple screens to complete an action). Despite nurses being the largest workforce using EHRs, there is limited research focused on the needs of nurses in EHR design.