Delays in Diagnosis, Treatment, and Surgery: Root Causes, Actions Taken, and Recommendations for Healthcare Improvement.

Objectives: Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients.

Evaluation of Protective Properties of Commercially Available Medical Helmets: Are Medical Helmets Protective?

Objectives: The aims of the study were to evaluate and to compare protective properties of commercially available medical helmets for a set of standardized head injury risk measures.

Methods: Eleven helmet types were evaluated to represent the variety of commercially available medical helmet designs and manufacturers. A test mannequin and sensor apparatus were used to simulate a backward-standing fall.

Power Failures During Surgery: A 2000-2019 Review of Reported Events in the Veterans Health Administration.

Objectives: The frequency and impact of power failure on surgical care over time in a large integrated healthcare system such as the Veterans Health Administration (VHA) is unknown. Reducing the likelihood of harm related to these rare but potential catastrophic events is imperative to ensuring patient safety and high-quality surgical care. This study provides analysis and description of reported power failures during surgery (January 2000-March 2019), in the VHA and their impact.

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).

Implementing Evidence-Based Pressure Injury Prevention Interventions: Veterans Health Administration Quality Improvement Collaborative.

Background: Pressure injury prevention is a persistent concern in nursing. The Veterans Health Administration implemented a creative approach with successful outcomes across the United States.

Problem: Pressure injury prevention is a measure of nursing quality of care and a high priority in the Veterans Health Administration.

The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration.

Objectives: The aim of the study was to compare retained surgical item (RSI) rates for 137 Veterans Health Administration Surgery Programs with and without surgical count technology and the root cause analysis (RCA) for soft good RSI events between October 1, 2009 and December 31, 2016. A 2017 survey identified 46 programs to have independently acquired surgical count technology.

Methods: Retained surgical item rates were calculated by the sum of events (sharp, soft good, instrument) divided by the total procedures performed.

Teaching Root Cause Analysis Using Simulation: Curriculum and Outcomes.

Background: Clinicians are key drivers for improving health care quality and safety. However, some may lack experience in quality improvement and patient safety (QI/PS) methodologies, including root cause analysis (RCA).

Objective: The Department of Veterans Affairs (VA) sought to develop a simulation approach to teach clinicians from the VA's Chief Resident in Quality and Safety program about RCA.

Falls in Veterans Healthcare Administration Hospitals: Prevalence and Trends.

Introduction: To provide up-to-date data on fall prevalence and trends in Veterans Health Administration (VHA) hospitals.

Methods: Data were collected by the VHA Inpatient Evaluation Center (IPEC) between 2011 and 2017, to establish prevalence and trends of falls and major injuries occurring in acute care/intensive care units (AC/ICU), behavior health (BH), and community living center (CLC)/long-term care, using bed days of care (BDOC) as denominators.

Results: A total of 204,681 falls were reported (rate = 4.

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.

Recommendations for Fall-Related Injury Prevention: A 1-Year Review of Fall-Related Root Cause Analyses in the Veterans Health Administration.

Background: Injurious falls continue to challenge health care. Causes of serious falls from the largest health care system in the United States can direct future prevention efforts.

Purpose: This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events.

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.

How to do a Virtual Breakthrough Series Collaborative.

Despite widespread use of the breakthrough series (BTS) collaborative in healthcare, there is limited literature on how to operationalize the method in healthcare settings. A recent modification to the model is the virtual breakthrough series (VBTS), in which all work is done remotely via telephone and web-based platforms. With virtual methods gaining popularity, this manuscript presents guidance on methods to conduct a virtual breakthrough series collaborative to assist clinical teams in implementing evidence-based practices.

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.

Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration.

Purpose: Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence.

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.

Improving Patient Safety Culture: A Report of a Multifaceted Intervention.

Objective: The aim of the study was to improve the safety culture at a Veterans Administration hospital using evidence-based approaches.

Methods: We implemented a patient safety summit with follow-up actions. We measured safety climate before and after the summit using the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety Culture with modifications and the Safety Attitudes Questionnaire (SAQ).

Preventing Falls and Fall-Related Injuries in State Veterans Homes: Virtual Breakthrough Series Collaborative.

This article reports on improved processes and outcomes from a virtual breakthrough series quality improvement collaborative to reduce preventable falls and fall-related injuries in 23 State Veterans Homes. Participating teams implemented 24 interventions (process changes); the most common was the postfall huddle. Teams reduced falls and fall-related injuries.

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.

Impact of The Daily Plan on Length of Stay and Readmission.

The Veterans Health Administration implemented The Daily Plan (TDP) to improve patient safety. We compared length of stay and readmission between intervention and control units. Length of stay decreased for both groups.

Virtual Breakthrough Series, Part 2: Improving Fall Prevention Practices in the Veterans Health Administration.

Background: The Veterans Health Administration (VHA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help prevent falls and fall-related injuries. This project enabled teams to expand program infrastructure, redesign improvement strategies, and enhance program evaluation.

Methods: A VBTS collaborative involves prework, action, and continuous improvement.

Virtual Breakthrough Series, Part 1: Preventing Catheter-Associated Urinary Tract Infection and Hospital-Acquired Pressure Ulcers in the Veterans Health Administration.

Background: In 2014 the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help VHA facilities prevent hospital-acquired conditions: catheter-associated urinary tract infection (CAUTI) and hospital-acquired pressure ulcers (HAPUs).

Methods: During the prework phase, participating facilities assembled a multidisciplinary team, assessed their current system for CAUTI or HAPU prevention, and examined baseline data to set improvement aims. The action phase consisted of educational conference calls, coaching, and monthly team reports.

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.

Preventing Pressure Ulcers in the Veterans Health Administration Using a Virtual Breakthrough Series Collaborative.

The Veterans Health Administration implemented a Virtual Breakthrough Series to prevent pressure ulcers. The pressure ulcer rate decreased from 1.2 to 0.