A Framework for the Analysis of Communication Errors in Health Care.

Objectives: The goal of this study was to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. We aimed to develop a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.

Methods: This observational study used the Delphi method to develop a taxonomy code sheet for identifying communication errors reported in the Veterans Health Administration patient safety databases between April 2018 and March 2021.

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.

Urinary Retention Evaluation and Catheterization Algorithm for Adult Inpatients.

Importance: Acute urinary retention (UR) is common, yet variations in diagnosis and management can lead to inappropriate catheterization and harm.

Objective: To develop an algorithm for screening and management of UR among adult inpatients.

Design, Setting, And Participants: In this mixed-methods study using the RAND/UCLA Appropriateness Method and qualitative interviews, an 11-member multidisciplinary expert panel of nurses and physicians from across the US used a formal multi-round process from March to May 2015 to rate 107 clinical scenarios involving diagnosis and management of adult UR in postoperative and medical inpatients.

Quality improvement lessons learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook".

Objective: To evaluate nationwide implementation of a Guidebook designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., Community Care) and identify lessons learned and strategies to improve them.

Veterans Health Administration response to 2021 recall of Philips Respironics devices: A case study.

This case study describes, for the time frame of June 2021 through August 2022, the U.S. Veterans Health Administration (VHA) organizational response to a manufacturer's recall of positive airway pressure devices used in the treatment of sleep disordered breathing.

Original Research: What Health Care Staff Who Experienced Assisted Patient Falls Can Teach Us: Implications for Fall and Fall Injury Risk.

Purpose: This quality improvement project had three aims: to identify common assisted falls scenarios, describe staff members' experiences with and risk perceptions of such falls, and explore factors that influenced their perceptions. The overarching goal was to gain useful insight for the development of assisted fall-related strategies and policies.

Methods: In the fall of 2020, 16 staff members from 13 health care facilities were purposively recruited and interviewed.

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.

Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers.

Introduction: Adverse events in urologic procedures are poorly studied. This study analyzes the Veterans Health Administration (VHA) Root Cause Analysis (RCA) data for patient safety adverse events during urologic procedures performed in a VHA operating room (OR).

Materials And Methods: The VHA National Center for Patient Safety RCA database was queried for fiscal years 2015-2019 using urologic terms including vasectomy, prostatectomy, nephrectomy, cystectomy, cystoscopy, lithotripsy, ureteroscopy, urethral, TURBT, etc.

Level of Care Appropriateness in VA Inpatient Surgery Cases.

Purpose Of Study: Within the Veterans Health Administration, utilization management (UM) focuses on reducing unnecessary or inappropriate hospitalizations by applying evidence-based criteria to evaluate whether the patient is placed in the right level of care. This study examined inpatient surgery cases to classify reasons for not meeting criteria and to identify the appropriate level of care for admissions and subsequent bed days of care.

Primary Practice Settings: There were 129 VA Medical Centers in which inpatient UM reviews were performed during that time, of which 109 facilities had UM reviews conducted in Surgery Service.

A Scoring Rubric for the Knowledge Section of the Systems Quality Improvement Training and Assessment Tool.

Introduction: Quality improvement (QI) competencies for health professions trainees were developed to address health care quality. Strategies to integrate QI into curricula exist, but methods for assessing interdisciplinary learners' competency are less developed. We refined the Knowledge section scoring rubric of the Systems Quality Improvement Training and Assessment Tool (SQI TAT) and examined its validity evidence.

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.

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.

Veterans Health Administration Scheduling System: The Path to High Reliability Realization.

Timely access to services is the gateway to patient safety and quality, and scheduling is foundational to providing access to highly reliable care. An effective and efficient scheduling strategy is dependent on an evidence-based approach that focuses on critical drivers of the scheduling system related to patient safety and quality as well as access. As part of a continuing effort to improve access, the Veterans Health Administration (VHA) completed a direct causation analysis (2015-2020) using an evidence-based framework and comprehensive measurement plan.

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration.

Objectives: Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy.

Methods: From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff.

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.

Delirious Mania: An Approach to Diagnosis and Treatment.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Cardiac Telemetry Downtime and Contingency Plan Development: A Review of Downtime Events Reported in the Veterans Health Administration.

Background: Cardiac telemetry downtime may be planned or unplanned, causing a disruption in telemetry services with a potential to impact patient safety.

Problem: Many cardiac telemetry units in the Veterans Health Administration (VHA) have contingency plans that do not adequately address telemetry downtime.

Approach: This is a retrospective quality improvement analysis of VHA-reported cardiac telemetry downtime events from October 1, 2014, to Mar 31, 2020.