US House of Representatives Committee on Veterans Affairs Subcommittee on Oversight and Investigations. 116th Cong, 1st Sess (2019).
The Veterans Affairs (VA) health system is responsible for both systemic achievements and challenges. This hearing examined a series of problems occurring in the VA system including unexplained deaths of patients. Strategies presented during testimony to remedy these situations include improving employee background checks, credentialing gaps and response to reported clinician performance concerns.
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Although adverse events and near misses are common in health care, they are almost ubiquitously underreported. Barriers to reporting include health care provider fear of repercussions, insufficient integration of reporting systems into the electronic health record, and cultural factors. This new sentinel event alert explores how organizations can change their culture to promote reporting. It highlights bright spots: organizations that use a just culture approach to investigating errors, celebrate employees who report safety hazards, and whose leaders prioritize reporting. The Joint Commission proposes actions for all organizations to take, including developing incident reporting systems, promoting leadership buy-in, engaging in systemwide communication, and implementing transparent accountability structures. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
American Hospital Association; AHA; Federation of American Hospitals.
The ability to share data about medical errors in a protected environment is core to the patient safety organization concept. In this brief, authors advocate for the value these protections bring to health care by enabling the transparency needed to improve safety as they request the United States Supreme Court to hear a case that challenges these privileges.
The Veterans Affairs (VA) health system has both achieved success and struggled to provide safe care to its patients. In an effort to address shortcomings in care, this bill allocates additional funding to the VA. Goals of this legislation include regulating and improving staffing levels, enabling veterans to access non-VA facilities, and enhancing patient access to telemedicine.
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