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Search results for "Department of Veterans Affairs (VA)"
Journal Article > Commentary
Soncrant CM, Warner LJ, Neily J, et al. AORN J. 2018;108:386-397.
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.
Special or Theme Issue
J Am Coll Surg. 2011;212:921-990.
Articles in this special issue explore the effectiveness of AHRQ Patient Safety Indicators in VA hospitals.
Journal Article > Study
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.
Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.
The Veterans Health Administration has pioneered implementation of several innovative safety interventions, including teamwork training (using the Medical Team Training model) for surgical and intensive care unit staff. This report on the early effects of the teamwork training initiative found positive perceptions of the impact on teamwork, communication, efficiency, and patient safety. This preliminary study also provides examples of changes in participant behavior and clinical outcomes associated with implementation of the teamwork program. Failure to report these outcomes is a common limitation of teamwork training studies, as discussed in a recent systematic review.
Journal Article > Study
Volpp KG, Rosen AK, Rosenbaum PR, et al. J Gen Intern Med. 2009;10:1149-1155.
The safety impact of the ACGME trainee work hour restrictions remains controversial due to contrasting findings that have suggested benefit, harm, and no significant impact. This observational study analyzed all Medicare patients admitted to acute care facilities with a predefined set of primary diagnoses to estimate the 30-day mortality among high-severity medical admissions and the failure to rescue in postoperative surgical admissions. Investigators found no significant harm or benefit to patients with higher-severity illness compared with those with lower risk among both the medical and surgical patients. A past AHRQ WebM&M perspective discussed the impact of fatigue and extended shifts among trainees on the incidence of medical errors.