Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 3
- Education and Training 3
- Error Reporting and Analysis 12
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Quality Improvement Strategies 5
- Transparency and Accountability 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 5
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
- Health Care Executives and Administrators 16
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 1
Search results for "Department of Veterans Affairs (VA)"
- Government Resource
- Department of Veterans Affairs (VA)
Veazie S, Peterson K, Bourne D. Washington, DC: Department of Veterans Affairs; May 2019.
This brief evaluated published accounts of frameworks for implementing high reliability organizations to examine which approaches have been most successful. The analysis identified five common implementation strategies: leadership development, data system utilization, quality improvement interventions, training and learning, and safety culture.
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.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.
Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures. Highlighting concerns at one medical center that were found to contribute to opportunities for waste, fraud, and poor health care delivery, this report by the Office of Inspector General outlines 40 recommendations to address deficiencies.
VA National Center for Patient Safety.
The Department of Veterans Affairs consistently contributes to innovation and improvement efforts in patient safety. This podcast series offers short interviews with experts in the field that explore topics such as the VA National Center for Patient Safety leadership development program and a checklist for use in mental health facilities.
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.
The Veterans Health Administration faces various challenges to providing safe care, including poor continuity during transitions to different locations which can result in inappropriate discontinuation of medications that patients require. This government report discuses efforts to reduce gaps in medication access and suggests developing clear policies to prevent patient harm in this population.
Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.
Washington, DC: VA Office of Inspector General. August 6, 2015. Report No. 15-02131-471.
Drug–drug interactions resulting in adverse drug events are common causes of preventable harm to patients. This investigation determined that mixed drug toxicity was the cause of a patient's death at a Veterans Affairs facility and factors that contributed to the incident included lack of teamwork, informed consent, emergency response efforts, and equipment access.
Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643.
The National Center for Patient Safety (NCPS) has contributed to patient safety improvement initiatives in the Department of Veterans Affairs (VA) since its inception. This investigation explored VA medical centers' application of root cause analysis after adverse events and how findings from these analyses were used to make system-wide improvements. This report found that the number of root cause analyses performed has decreased and the NCPS has not yet sought to determine why, but factors such as use of other incident analysis methods may have contributed. The Government Accountability Office recommends that the VA assess reasons behind the decline in use of root cause analysis and the extent to which alternative strategies are being utilized.
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.
Audiovisual > Audiovisual Presentation
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014). (Testimony of Richard Griffin; Robert A. McDonald.)
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
The Veterans Health Administration has earned widespread praise for improving quality of care during the past decade, but this report by the Veterans Affairs (VA) Office of the Inspector General exposes serious problems within the Phoenix VA facility, which may be representative of system-wide issues with access to care. Even though the facility officially reported average wait times of only 24 days, the investigation found that veterans typically waited nearly 4 months for a new primary care appointment. This discrepancy was due to systematic manipulation of the scheduling system—more than 1700 patients had requested an appointment but were never enrolled on the waiting list for scheduling. Because wait times for primary care appointments were a VA quality metric, clinics likely resorted to gaming the system to appear to achieve their targets. The report indicates that evidence of inappropriate manipulation of the scheduling process has been found at many other VA facilities as well. The study did not formally address whether these delays in care directly led to deaths or preventable harm. An investigation of specific cases of deaths among patients who were waiting for appointments is ongoing and is expected to be released later this year.
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.
DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers.
Washington, DC: United States Government Accountability Office; November 2, 2012. Publication GAO-13-26.
This government report reveals the need for a policy to ensure that veterans' medication needs are safely managed during transitions between health care providers.
Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.
Washington, DC: United States Government Accountability Office; August 2012. Publication GAO-12-827R.
This report describes an analysis of incident reporting systems used in Veterans Health Administration medical centers to explore how the collected information is acted upon.
Washington, DC: VA Office of Inspector General; April 20, 2012. Report No. 12-00956-159.
This publication presents findings from an investigation, prompted by reports of alarm fatigue, which identified gaps in training and competencies of nurses in 29 Veterans Health Administration facilities.
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.
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.
Tools/Toolkit > Government Resource
VA National Center for Patient Safety.
These materials provide an introduction to the purpose of healthcare failure mode and effect analysis (HFMEA), the steps of the HFMEA process, and how to apply the technique to address the Joint Commission proactive risk assessment standard.
US Government Accountability Office. Washington, DC: US Government Accountability Office; 2004. Publication GAO-05-83.
The Government Accountability Office studied patient safety programs at four Department of Veterans Affairs (VA) health facilities and recommends that the VA emphasize leadership action and open communication to support safety improvement.