Healthcare organizations use multiple proactive and reactive methods of investigating and preventing adverse events. This study combined proactive and reactive risk assessments into a Combined Proactive Risk Assessment (CPRA) to identify risks not detected by one method on its own. The four steps of CPRA are illustrated using the example of outpatient blood draws in the Veterans Health Administration.

… J Patient Saf … Dialysis is a common procedure that carries risks if not performed … method for hemodialysis delivery. … Walton E,  Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an …

Using data from the Veterans Health Administration National Center for Patient Safety, this retrospective study found that suicide and opioid overdose are the most serious healthcare-related adverse events affecting homeless veterans. Identified root causes include issues related to risk assessment for suicidal or overdose behaviors as well as poor interdisciplinary communication and coordination of care.

… Patient Saf … Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause …

… high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. Epub 2020 Sept 11. …

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.

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.  

… firearms, and close observation. … Mills PD, Soncrant C, Gunnar W. Retrospective analysis of reported suicide deaths …

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.

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.

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.

This analysis of the Veterans Health Administration root cause analysis database found that wrong surgery events can occur despite adherence to the Universal Protocol, due to errors preceding and following the protocol's use. The authors suggest that additional processes initialized earlier and continuing later through the surgical process are required to fully prevent these events.

This study examined inpatient suicides at Veterans Affairs hospitals and provided recommendations for mitigating risks. Hanging by using equipment present in psychiatric wards was the most common method of suicide.

The Veterans Affairs (VA) system has published important studies on the incidence of wrong-site, wrong-procedure, and wrong-patient surgery. This study reports on the VA's effort to disseminate lessons from these events to prevent further such errors.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.