Establishing a Just Culture: Implications for the Veterans Health Administration Journey to High Reliability.

Background: To establish a culture of safety and improve patient care, the Veterans Health Administration (VHA) is identifying and implementing necessary parameters and objectives across the health care landscape to enhance services on its journey to becoming a high reliability organization (HRO).

Methods: This quality improvement initiative sought to increase the understanding of factors that influence the establishment and sustainment of a just culture and identify specific methods for improving their implementation. Focus groups of HRO leads at 16 VHA hospital facilities identified emergent themes, facilitators, and barriers to maintaining a just culture and developed recommendations for enhancing both psychological safety and accountabilitity.

Implementation of a High-Reliability Organization Framework in a Large Integrated Health Care System: A Pre-Post Quasi-Experimental Quality Improvement Project.

Introduction: The purpose of this quality improvement (QI) project was to evaluate outcomes across Veterans Health Administration (VHA) hospital facilities engaged in an enterprise-wide implementation of a high-reliability organization (HRO) framework.

Materials And Methods: This QI project relied on primary data drawn from 139 facilities nationwide from 2019 to 2023. Data sources included the All Employee Survey Patient Safety Culture (PSC) Module and patient safety reporting data derived from the Joint Patient Safety Reporting system.

Implementing Just Culture to Improve Patient Safety.

Introduction: The number of deaths in the United States related to medical errors remains unacceptably high. Further complicating this situation is the problem of underreporting due to the fear of the consequences. In fact, the most commonly reported cause of underreporting worldwide is the fear of the negative consequences associated with reporting.

A High-Reliability Organization Framework for Health Care: A Multiyear Implementation Strategy and Associated Outcomes.

Objectives: Applying high-reliability organization (HRO) principles to health care is complex. No consensus exists as to an effective framework for HRO implementation or the direct impact of adoption.

Methods: The Veterans Health Administration (VHA) National Center for Patient Safety established the high-reliability hospital (HRH) model for HRO adoption and piloted HRH in collaboration with the Truman VA Medical Center (Truman) during a 3-year intervention period (January 1, 2016-December 31, 2018).

Checklist design and implementation: critical considerations to improve patient safety for low-frequency, high-risk patient events.

Purpose: This pilot project describes the development and implementation of two specialised aviation-style checklist designs for a low-frequency high-risk patient population in a cardiac intensive care unit. The effect of the checklist design as well as the implementation strategies on patient outcomes and adherence to best practice guidelines were also explored. The long-term objective was to improve adherence to accepted processes of care by establishing the checklists as standard practice thereby improving patient safety and outcomes.

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.

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.

A concept analysis of situational awareness in nursing.

Aim: This article reports an analysis of the concept of situational awareness in nursing.

Background: Situational awareness is a fundamental and well-understood concept used to maintain operational safety in high reliability organizations; however, it has not been studied in nursing. Nurses play a critical role in providing vigilance in health care and what they do or fail to do is directly related to patient outcomes.

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

In response to low scores on a patient safety culture survey, the Veterans Health Administration National Center for Patient Safety implemented a comprehensive nursing-focused crew resource management program for frontline nursing staff. This article highlights significant cultural and clinical outcomes from the program.

Improving nursing students' communication skills using crew resource management strategies.

To provide optimal patient care, all members of the health care team must effectively communicate patient status and the current plan of care. The Crew Resource Management (CRM) training system has been successfully used in the aviation industry to manage human error and reduce risk in the operational environment. CRM focuses on behaviors that support communication and teamwork and is modifiable to be used in nursing education.

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project.

Aim:   To implement the sterile cockpit principle to decrease interruptions and distractions during high volume medication administration and reduce the number of medication errors.

Background:   While some studies have described the importance of reducing interruptions as a tactic to reduce medication errors, work is needed to assess the impact on patient outcomes.

Methods:   Data regarding the type and frequency of distractions were collected during the first 11 weeks of implementation.

Improving patient safety and optimizing nursing teamwork using crew resource management techniques.

Objective: This project describes the application of the "sterile cockpit rule," a crew resource management (CRM) technique, targeted to improve efficacy and safety for nursing assistants in the performance of patient care duties.

Background: Crew resource management techniques have been successfully implemented in the aviation industry to improve flight safety. Application of these techniques can improve patient safety in medical settings.

The case for training Veterans Administration frontline nurses in crew resource management.

Using cultural analysis, the authors present a rationale for a nursing-focused crew resource management (CRM) program in the Veterans Health Administration. Although the value of CRM in aviation is well documented and CRM has been successfully applied in healthcare settings to improve communication and teamwork, there is little evidence outlining the implementation of CRM on nursing units with nursing as the primary focus. This article describes the preproject data supporting a nursing-focused CRM program called nursing CRM.