Adverse Patient Safety Events During the COVID-19 Epidemic.

Methods: A retrospective descriptive analysis of patient safety events related to COVID-19 was performed on data that were submitted in the Joint Patient Safety Event Reporting System and Root Cause Analysis databases to the VHA National Center for Patient Safety from March 2020 to February 2021. Events were coded for type of event, location, and cause of event.

Results: Delays in care and staff/patients exposed to COVID-19 were the most common types of patient safety events, followed by COVID-19-positive patients eloping, laboratory processing errors, and one wrong procedure.

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).

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.