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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 2
- Medication Safety 1
- Psychological and Social Complications 1
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Tools/Toolkit > Toolkit
Ann Arbor, MI: National Center for Patient Safety; 2004.
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in implementing or improving falls prevention efforts. The toolkit provides information on (1) designing a falls prevention and management program; (2) effective interventions for high-risk fall patients; (3) implementing hip protectors for high-risk fall patients; and (4) educating patients, families, and staff on falls and fall-injury prevention. The web version of the toolkit includes a falls notebook for practitioners implementing a program, media tools, and additional resources.
Legislation/Regulation > Organizational Policy/Guidelines
Veterans Health Administration. Washington DC: Department of Veterans Affairs; October 27, 2005. VHA Directive 2008-02.
This Veterans Health Administration (VHA) directive provides direction for disclosing medical mistakes to patients and their families. The policy addresses actions that specific VHA staff members should take during the disclosure process.
Journal Article > Study
Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration.
Mills PD, Neily J, Luan D, Osborne A, Howard K. Jt Comm J Qual Patient Saf. 2006;32:130-141.
The investigators examined root cause analyses regarding suicide and parasuicidal behaviors. They found that underreporting of parasuicidal events complicates efforts to prevent suicides or improve outcomes.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.
VA National Center for Patient Safety. Washington, DC: VA Central Office; April 6, 2006. Patient Safety Alert AL06-012.
This alert reports five instances of accidental infusion into an IV or peripherally inserted central catheter (PICC) line and suggests actions for preventing similar errors.
Journal Article > Study
How active resisters and organizational constipators affect health care–acquired infection prevention efforts.
Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. Jt Comm J Qual Patient Saf. 2009;35:239-246.
This study uses qualitative methods—and biting humor—to vividly illustrate how building a culture of safety often requires identifying and dealing with individuals who are resistant to change.
Journal Article > Review
Jackson PD, Biggins MS, Cowan L, French B, Hopkins SL, Uphold CR. Rehabil Nurs. 2016;41:135-148.
Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.