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Search results for "Department of Veterans Affairs (VA)"
Web Resource > Course Material/Curriculum
Ann Arbor, MI: National Center for Patient Safety.
This curriculum introduces basic patient safety concepts and provides materials to support students, instructors, and faculty educators.
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.
Journal Article > Study
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.
Subcommittee on Oversight and Investigations, 109th Cong, 2nd Sess (June 15, 2006). (Testimony of James P. Bagian, MD, PE; John D. Daigh, Jr., MD; Daniel Schultz, MD; Laurie Ekstrand).
These testimonies addressed issues within the Veterans Affairs health system that contributed to recent sterilization and labeling lapses.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
The Agency for Healthcare Research and Quality announces the 2007–2008 Patient Safety Improvement Corps (PSIC) program. States and organizations participating in the program will select staff members and its hospital partners to train in patient safety improvement. The applications period for this program cycle is now closed.
Journal Article > Commentary
Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about.
Bagian JP, Lee C, Gosbee J, et al. Jt Comm J Qual Improv. 2001;27:522-532.