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.

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.

Delays in Care During the COVID-19 Pandemic in the Veterans Health Administration.

Objectives: The purpose of this study was to review patient safety reports in the Veterans Health Administration (VHA) related to delays during an 11-month period that included months of the COVID-19 pandemic.

Design: A retrospective descriptive analysis of COVID-19 patient safety reports related to delays that were submitted in the Joint Patient Safety Event Reporting System database to the VHA National Center of Patient Safety from January 01, 2020 to November 15, 2020 was conducted. There were 897 COVID-19 patient safety events related to delays; 200 cases were randomly selected for analysis, with 148 meeting inclusion criteria.

Review of Reported Adverse Events Occurring Among the Homeless Veteran Population in the Veterans Health Administration.

Background: United States veterans face an even greater risk of homelessness and associated medical conditions, mental health conditions, and fatal and nonfatal overdose as compared with nonveterans. Beginning 2009, the Department of Veterans Affairs developed a strategy and allocated considerable resources to address veteran homelessness and the medical conditions commonly associated with this condition.

Objective: This study aimed to examine the Veterans Health Administration National Center for Patient Safety database for patient safety events in the homeless veteran population to mitigate future risk and inform policy.

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).