Narrow Results Clear All
Search results for ""
Web Resource > Government Resource
United States Department of Defense.
This Web site includes information on several initiatives within the US Military Health System to support its culture of safety and reduce medical error through leadership, transparency, teamwork, and communication.
Legislation/Regulation > Federal Legislation
HR 3230, 113th Congress (2014).
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.
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.
Tracking concerns related to individual clinician performance has the potential to uncover opportunities for clinician skill and system safety enhancements. This report highlights weaknesses in the peer reporting processes of Veterans Affairs medical centers and offers recommendations to improve the quality and timeliness of reporting to ensure safety of patients in the VA system.
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0030-EF.
A vibrant culture of safety is critical to achieving high reliability in health care. Organizations with stronger safety culture boast lower in-hospital mortality and fewer surgical site infections. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2018 comparative database report assessed 10 safety culture domains in nearly 2500 ambulatory care practices. Respondents reported high rates of teamwork and strong systems for patient follow-up. Many practices identified productivity pressures and work pace as safety hazards. Although the practices surveyed are not nationally representative, they do allow leaders and scientists to compare safety culture across practices and time. A past WebM&M commentary examined safety hazards associated with productivity pressures in health care.
Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
Adverse event reporting is an important step toward failure reduction. However, weaknesses in feedback, follow-up, and action resulting from incident reports diminish their impact on safety. This publication analyzed reporting activity and action in the Defense Health Agency. The resulting recommendations suggest the need to improve tracking of incident reports and for clarifying reporting requirements.
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
Ineffectively prescribed opioids contribute to opioid misuse and overdose among patients. This report analyzed activities at five Veterans Health Administration facilities and found inconsistent application of opioid safety strategies in the system. System-level recommendations to enhance practice include cross-system tracking efforts with defined goals and establishing a pain management leadership role at each facility.
Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.
Both organizational and individual accountability are required to ensure safe care. This analysis of Department of Veterans Affairs (VA) responses to whistle-blower concerns and reports of staff misconduct found that the VA has procedures for investigating these allegations but determined that the process was unreliable. The report outlines recommendations for improvement including ensuring whistle-blowers are treated fairly and assigning responsibilities across the hierarchy to ensure incidents receive the appropriate attention.