Search results for "Department of Veterans Affairs (VA)"

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.

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.

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.

This curriculum introduces basic patient safety concepts and provides materials to support students, instructors, and faculty educators.

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.

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.

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.

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.

This investigation into three patients who died in an emergency department uncovered problems related to medication ordering, alert response, and test result tracking.

The NCPS represents a unified and cohesive patient safety effort. The program, which won the John Eisenberg Award in 2002, is unique in health care. It focuses on prevention rather than punishment by applying human factors analysis and the safety research of high-reliability organizations. This process is targeted at identifying and eliminating system vulnerabilities.

This government report reveals the need for a policy to ensure that veterans' medication needs are safely managed during transitions between health care providers.

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.

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.

The GAPS Center (Getting At Patient Safety) aims to create, test, validate, and refine tools for health care workers and managers to use in coping with safety threats.

The Department of Veterans' Affairs funded the James A. Haley Veterans Hospital, Tampa, to establish a VISN 8 Patient Safety Center of Inquiry. The Center was originally funded for three years in 1999 and has continued to receive funding to the present time. The focus of the center is safe mobility, and two of their goals are the to promote personal freedom and safety for frail elderly and persons with disabilities across the continuum of care and to build a culture of safety to support clinicians in providing safe patient care and working environments.

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.

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.

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.

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.

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.