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Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

Washington, DC: Department of Veterans Affairs, Office of Inspector General.  July 29, 2021. Report No. 21-00657-197.

Care coordination effectiveness is tested by time, hierarchy, and practice silos. This report examines allegations affecting medication access enabled by poor communication, workforce absences, and the built environment challenges. While care coordination challenges in this case were unsubstantiated, the report highlights lack of clinical review and inaccurate analysis of patient death as concerns.

Houston, TX:  Baylor College of Medicine.

This Center represents a partnership with the Veterans Affairs Health Services Research & Development Center of Innovation to enhance researchers' skills through active participation in diagnostic safety research and policy development. The goals of the program include a focus on behavioral health interventions and measurement.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Washington DC:  Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140.

Health care system failures can enable unrecognized, persistent criminal behavior. This report examines conditions contributing to a serial murder case including weaknesses in mortality data analysis, clinical documentation review, patient safety incident reporting, medication security processes, and safety culture.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

 

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed. 
Sculli GL, Pendley-Louis R, Neily J, et al. J Patient Saf. 2020;Epub Oct 13.
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.
Kulju S, Morrish W, King LA, et al. J Patient Saf. 2020;Epub Sept 15.
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.  

Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.
Bloomfield HE, Greer N, Linsky AM, et al. J Gen Intern Med. 2020;35(11):3323-3332.
Deprescribing is one strategy to reduce polypharmacy among older adults. This systematic review found that medication deprescribing interventions (particularly those involving comprehensive medication review) may provide small reductions in mortality and use of potentially inappropriate medications among community-dwelling older adults.

VHA Forum. Summer 2020;1-12.

High reliability attainment is a stated goal for health care organizations. This special issue covers established initiatives at the United States Veterans Health Administration that draw from high reliability principles to improve care. Topics covered include evaluation priorities, safe patient handling and diagnostic safety.
Quach ED, Kazis LE, Zhao S, et al. J Am Med Dir Assoc. 2021;22(2):388-392.
This cross-sectional study examined the impact of safety climate on adverse events occurring in Veterans Administration (VA) nursing homes and community living centers. Survey results suggest that nursing homes may reduce adverse events by increasing supportive supervision and a safer physical environment. The survey found that supervisor commitment to safety was associated with lower rates of major injuries from falls and catheter use, and that environmental safety was associated with lower rates of pressure ulcers, major injuries from falls, and catheter use.

Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.   
Gaur S, Dumyati G, Nace DA, et al. Infect Control Hosp Epidemiol. 2020;41(6):729-730.
This commentary discusses the provision of safe care in long-term care settings during the COVID-19 pandemic. The authors propose the following measures to ensure the safety of long-term care patients: facilities should only accept patients with COVID-19 infections if they can provide effective airborne isolation; patients recovering from COVID-19 need to have 2 negative tests on 2 consecutive days, as well as remain fever-free without mediation for at least 48 hours and not require ventilatory support that generates aerosols; facilities should screen potential admissions for typical and atypical signs and symptoms of COVID-19, and; facilities that are currently COVID-19 naïve should not accept any new admissions for whom there may be a concern for COVID-19.
Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16(4):255-258.
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.
George J, Elwy AR, Charns MP, et al. Jt Comm J Qual Patient. 2020.
This retrospective study explored whether staff perceptions of organizational culture at the Department of Veterans Affairs (VA) were associated with large-scale adverse events. The authors found an inverse association between a supportive organizational culture and the incidence of large-scale adverse events. Results suggest that in hospitals with reciprocal engagement (i.e., staff perceptions that the organization cares about the employee), staff are more likely to adhere to safety practices that prevent or mitigate large-scale adverse events.
Oliva EM, Bowe T, Manhapra A, et al. BMJ. 2020;386:m283.
Guidelines recommend safe opioid prescribing but also warn against sudden tapering or discontinuation of opioids, which can lead to harm among patients physically dependent on the medications. Using data from the Veterans Heath Administration (VA), this observational study examined the association between opioid treatment cessation and death from overdose or suicide. Researchers found an increased risk of death from overdose or suicide regardless of the length of treatment; the risk of death increased with longer treatment duration. The authors recommend that efforts to improve opioid safety include assessing risks that may place patients at risk for overdose or suicide whether they continue or stop opioid treatment.
Soncrant C, Mills PD, Neily J, et al. J of Patient Saf. 2020;16.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Gill S, Mills PD, Watts BV, et al. J Patient Saf. 2020;Epub Feb 21.
This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).