Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

Previous studies have demonstrated that residents participating in patient safety event investigations become more engaged in future patient safety activities. Currently, there is a gap in resident participation in patient safety event analyses. The objective was to develop and implement a sustainable, faculty-led curriculum for resident participation in patient safety event investigations and to evaluate resident perceptions of the training at least one year following completion of the training.

The Pursuing Excellence Collaborative: Engaging First-Year Residents and Fellows in Patient Safety Event Investigations.

Objectives: Resident and fellow engagement in patient safety event investigations (PSEIs) can benefit both the clinical learning environment's ability to improve patient care and learners' problem-solving skills. The goals of this collaborative were to increase resident and fellow participation in these investigations and improve PSEI quality.

Methods: This collaborative involved 18 sites-8 sites that had participated in a similar previous collaborative (cohort I) and 10 "new" sites (cohort II).

How Should Risk Managers Respond to Cases for Which No Risk Profile Exists?

Rapid innovation makes some devices available for patient implantation prior to extensive preclinical trials. This article reviews information that risk managers can utilize to help patient-subjects and clinician-researchers make informed decisions about new device implantation in the absence of preclinical trial data. Novel devices should be regarded by risk managers as sources of unknowns with potential for procedural complications and other harms.

A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration.

Background: Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety.

Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide.

Objectives: The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact.

Methods: As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety.

Assessment of Incorrect Surgical Procedures Within and Outside the Operating Room: A Follow-up Study From US Veterans Health Administration Medical Centers.

Importance: Reducing wrong-site surgery is fundamental to safe, high-quality care. This is a follow-up study examining 8 years of reported surgical adverse events and root causes in the nation's largest integrated health care system.

Objectives: To provide a follow-up description of incorrect surgical procedures reported from 2010 to 2017 from US Veterans Health Administration (VHA) medical centers, compared with the previous studies of 2001 to 2006 and 2006 to 2009, and to recommend actions for future prevention of such events.

Wrong Site Spine Surgery in the Veterans Administration.

Study Design: Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA).

Objective: To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue.

Summary Of Background Data: Wrong site surgery is one of the most common events reported to The Joint Commission.

Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration.

This quality improvement project describes 22 OR patient falls reported in the Veterans Health Administration between January 2010 and February 2016. Most (n = 15; 68%) involved patient falls from the OR bed. Other patient falls (n = 6; 27%) occurred when the patient was transferred to or from the OR bed, and one fall (5%) occurred at another time.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units?

Background: Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting.

Methods: The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events.

Curriculum Development and Implementation of a National Interprofessional Fellowship in Patient Safety.

Objectives: Developing a workforce skilled in improving the safety of medical care has often been cited as an important means to achieve safer care. Although some educational programs geared toward patient safety have been developed, few advanced training programs have been described in the literature. We describe the development of a patient safety fellowship program.

Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem.

Objectives: The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention.

Methods: The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken.

The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities.

Communication failure is a significant source of adverse events in health care and a leading root cause of sentinel events reported to the Joint Commission. The Veterans Health Administration National Center for Patient Safety established Clinical Team Training (CTT) as a comprehensive program to enhance patient safety and to improve communication and teamwork among health care professionals. CTT is based on techniques used in aviation's Crew Resource Management (CRM) training.

Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned.

Background: Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events.

Root Cause Analyses of Reported Adverse Events Occurring During Gastrointestinal Scope and Tube Placement Procedures in the Veterans Health Association.

Objective: This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur.

Methods: This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database.

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork.

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time.

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

Background: The Universal Protocol has been associated with the prevention of wrong surgery procedures; however, such events still occur. This article explores wrong surgery events, defined as those incorrect procedures (wrong site, wrong side, wrong procedure, wrong patient, wrong level, wrong implant) that would have occurred despite the Universal Protocol including the performance of a time-out by the surgical team. Understanding why some of these events are not caught by the steps of the Universal Protocol, culminating in the time-out, can help the field to add upstream and downstream safeguards to help prevent these never events.

Examining Wrong Eye Implant Adverse Events in the Veterans Health Administration With a Focus on Prevention: A Preliminary Report.

Objective: The study goals were to examine wrong intraocular lens (IOL) implant adverse events in the Veterans Health Administration (VHA), identify root causes and contributing factors, and describe system changes that have been implemented to address this challenge.

Design: This study represents collaboration between the VHA's National Center for Patient Safety (NCPS) and the National Surgery Office (NSO).

Participants: This report includes 45 wrong IOL implant surgery adverse events reported to established VHA NCPS and NSO databases between July 1, 2006, and June 31, 2014.

Wrong-side thoracentesis: lessons learned from root cause analysis.

Importance: Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences.

Objectives: To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with their occurrence.

Design, Setting, And Participants: We searched the National Center for Patient Safety database for wrong-side thoracenteses performed in ambulatory clinics and hospital units other than the operating room reported from January 1, 2004, through December 31, 2011.

Institutional disclosure: promise and problems.

This study explores rationale for and barriers to the prompt and honest disclosure by healthcare organizations of care-related un-intended harm to patients. Although fear of legal action is frequently put forward as the reason that disclosure programs have been slow to be adopted by the medical community, social and nonjurisprudential explanations also pose challenges. This study identifies multiple facilitators and obstacles that transcend concerns about litigation and limit disclosure of adverse events that result in serious injury or death.

The effect of simulation-based crew resource management training on measurable teamwork and communication among interprofessional teams caring for postoperative patients.

Background: Many adverse events in health care are caused by teamwork and communication breakdown. This study was conducted to investigate the effect of a point-of-care simulation-based team training curriculum on measurable teamwork and communication skills in staff caring for postoperative patients.

Methods: Twelve facilities involving 334 perioperative surgical staff underwent simulation-based training.

Failure to obtain microbiological culture and its consequence in a mesh-related infection.

This report describes a case of a delayed diagnosis of a late-onset mesh infection due to an unexpected enteric pathogen, Enterobacter cloacae. A 62-year-old woman with a history of prior incisional hernia repair with a prosthetic mesh presented to the emergency room with signs of an abscess with surrounding cellulitis of her abdomen over a year after her hernia repair. The patient manifested minimal response to 1 month of oral antibiotics.

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005-12.