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Search results for "Health Care Executives and Administrators"

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Audiovisual

Patient Safety Huddle.

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.

Journal Article > Commentary

Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.

Gellad WF, Good CB, Shulkin DJ. JAMA Intern Med. 2017;177:611-612.

Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This commentary discusses US Veterans Affairs health system initiatives that focus on education, prescription monitoring, pain management, and use of guidelines to reduce risks associated with opioids.

Journal Article > Study

Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.

Oliva EM, Bowe T, Tavakoli S, et al. Psychol Serv. 2017;14:34-49.

Opioid-related harm is an urgent patient safety priority. Identifying patients at higher risk of harm is a critical aspect of opioid safety. This quality improvement team developed a predictive model, based on electronic health record data, to identify high-risk opioid users in order to provide targeted monitoring and intervention via a clinical decision support tool. The model included known risk factors for opioid-related harm, such as type of medication, dose, and coprescribed sedating medications as well as medical and mental health conditions. Investigators developed and validated the model using data from 2010 and tested its ability to predict overdose or suicide attempt in 2011. The model successfully and prospectively identified patients at risk for suicide attempt or overdose. They then used the electronic health record to provide physicians with an overdose or suicide risk estimate and a checklist of risk mitigation strategies at the point of care. The authors suggest that further study of the implementation of this risk mitigation strategy in primary care is needed.

Journal Article > Study

Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans.

  • Classic

Lin LA, Bohnert AS, Kerns RD, Clay MA, Ganoczy D, Ilgen MA. Pain. 2017;158:833-839.

Opioids are known to be high-risk medications, and unsafe prescribing practices are common. This intervention at Veterans Affairs medical centers used an electronic dashboard to provide feedback to clinicians about high-risk opioid prescribing. Local champions implemented the dashboard tool and spearheaded safer opioid prescribing. Using an interrupted time series analysis, researchers determined that the intervention reduced two unsafe prescribing practices: high-dose opioid prescriptions and concurrent use of opioids and benzodiazepines. The authors suggest that this type of large-scale intervention could be applied in other health care systems to enhance opioid safety. A recent Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to foster safer opioid use.

Journal Article > Study

Eight years of decreased methicillin-resistant Staphylococcus aureus health care–associated infections associated with a Veterans Affairs prevention initiative.

Evans ME, Kralovic SM, Simbartl LA, Jain R, Roselle GA. Am J Infect Control. 2017;45:13-16.

This retrospective study demonstrated declines in methicillin-resistant Staphylococcus aureus health care–associated infections between 2007–2015. Researchers attribute these results to implementation of the Veterans Affairs MRSA Prevention Initiative. These findings underscore the success of patient safety practices in reducing health care–associated infections.

Journal Article > Study

Dual health care system use and high-risk prescribing in patients with dementia: a national cohort study.

Thorpe JM, Thorpe CT, Gellad WF, et al. Ann Intern Med. 2017;166:157-163.

Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system.

Journal Article > Study

Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration.

Brennan PL, Del Re AC, Henderson PT, Trafton JA. Transl Behav Med. 2016;6:605-612.

Opioids are considered high-risk medications and overdoses are common. Guidelines have been developed to facilitate safe prescribing practices. This study across 141 facilities within the Department of Veterans Affairs (VA) health system demonstrated that as adherence to urine drug screening guidelines increased from 2010 to 2013, the risk of suicide and overdose events among VA patients receiving prescription opioids decreased over the same period. The authors conclude that opioid therapy guidelines may have a positive impact on patient safety.

Journal Article > Commentary

Reforming the Veterans Health Administration—beyond palliation of symptoms.

Giroir BP, Wilensky GR. N Engl J Med. 2015;373:1693-1695.

The Veterans Health Administration faces a myriad of challenges to providing safe care. This commentary highlights the importance of using a systems approach to address problems rather than treating each issue as an isolated case. The authors recommend ways to improve the safety of VHA services, including creating new classifications for leaders, committing to a culture of safety, and improving interoperability of electronic record systems.

Journal Article > Review

Evidence summary and recommendations for improved communication during care transitions.

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.

Book/Report

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.

Book/Report

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events.

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.

Journal Article > Study

Incidence- versus prevalence-based measures of inappropriate prescribing in the Veterans Health Administration.

Lund BC, Carrel M, Gellad WF, Chrischilles EA, Kaboli PJ. J Am Geriatr Soc. 2015;63:1601-1607.

This health system performance study ranked sites within the Veterans Affairs health system using two measures of potentially inappropriate prescribing in older veterans. Researchers found that sites ranked similarly when they used new potentially inappropriate medications to measure performance compared to when they used existing potentially inappropriate medications as the measure. These results suggest that measuring new potentially inappropriate prescriptions is a feasible strategy worthy of further study.

Journal Article > Study

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

Paull DE, Mazzia LM, Neily J, et al. Am J Surg. 2015;210:6-13.

This analysis of the Veterans Health Administration root cause analysis database found that wrong surgery events can occur despite adherence to the Universal Protocol, due to errors preceding and following the protocol's use. The authors suggest that additional processes initialized earlier and continuing later through the surgical process are required to fully prevent these events.

Journal Article > Study

Psychological safety and error reporting within Veterans Health Administration hospitals.

Derickson R, Fishman J, Osatuke K, Teclaw R, Ramsel D. J Patient Saf. 2015;11:60-66.

The hidden curriculum, disruptive behaviors, and hierarchy can influence health care workers' willingness to speak up about safety hazards. This study examined psychological safety, or the extent to which health care workers feel comfortable speaking up about patient safety. A substantial minority of employees stated that they would not report an error, most often due to fear of retaliation. As with prior studies of safety culture, workers with supervisory roles reported more positive feelings than frontline staff. These results underscore the need to implement a blame-free culture in order to promote patient safety. A past AHRQ WebM&M commentary discussed strategies to reduce disruptive behaviors and to enhance communication between nurses and physicians.

Journal Article > Study

Lack of timely follow-up of abnormal imaging results and radiologists' recommendations.

Al-Mutairi A, Meyer AND, Chang P, Singh H. J Am Coll Radiol. 2015;12:385-389.

This examination of abnormal imaging results found that patients recommended for additional imaging were often lost to follow-up. Because lack of timely follow-up can lead to delays in diagnosis, this work highlights a gap in current patient safety practices.

Book/Report

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.

Journal Article > Study

Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership.

Elwy AR, Bokhour BG, Maguire EM, et al. J Gen Intern Med. 2014;29(suppl 4):895-903.

This interview study examined how the Veterans Affairs medical centers disclosed large-scale adverse events to stakeholders. These incidents impacted multiple patients and included system failures as well as errors by individuals. Interviews with frontline staff, local leadership, and affected patients and family members examined strengths and weakness of the current disclosure process and elicited input for improvement. All stakeholders reinforced the need for tailored, interactive, multi-modal communication rather than standard mailed letters. While staff expressed the concern that adverse event disclosure led to loss of trust, patients and families stated that despite their initial distress they supported disclosure and follow-up care associated with large-scale adverse events. These findings are consistent with prior studies of error disclosure, but demonstrate a gap in frontline staff understanding of the rationale for disclosure.

Audiovisual > Audiovisual Presentation

The State of VA Health Care.

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.

Journal Article > Study

An analysis of electronic health record–related patient safety concerns.

  • Classic

Meeks DW, Smith MW, Taylor L, Sittig DF, Scott JM, Singh H. J Am Med Inform Assoc. 2014;21:1053-1059.

Health information technology is being rapidly utilized in the clinical environment, with recent data showing that most hospitals and clinics have implemented some form of electronic health record (EHR). In this context, this report from the Veterans Health Administration's Informatics Patient Safety Office is timely, as it uses a sociotechnical framework that takes into account both technical aspects and human factors engineering principles to analyze 100 safety incidents relating to the EHR. The authors found four categories of system flaws: mismatches between user needs and information displays, errors arising from software modification or updates, failures at the interface between the EHR and other clinical systems, and hidden dependencies within the system itself. Most of these issues were identified long after the EHR was implemented, highlighting the need for ongoing monitoring and optimization of EHRs to ensure their safety capabilities are being maximized. An error caused in part by lack of interoperability between two clinical information systems is discussed in a prior AHRQ WebM&M commentary.

Book/Report

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

  • Classic

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.

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