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.

Comparing Medications for DSM-5 PTSD in Routine VA Practice.

Objective: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD). One prior study using US Department of Veterans Affairs (VA) medical records data to compare these agents found no differences in symptom reduction in clinical practice. The current study addresses several weaknesses in that study, including limited standardization of treatment duration, inability to account for prior treatment receipt, use of an outdated symptomatic assessment for PTSD, and lack of functional outcome.

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).

Patient Misidentification Events in the Veterans Health Administration: A Comprehensive Review in the Context of High-Reliability Health Care.

Objectives: The Veterans Health Administration maintains national patient safety event reporting and root cause analysis (RCA) databases. These were reviewed to understand the prevalence of and provide insight into patient misidentification. The results were compared with a high-reliability health care framework.

Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review.

Objective: To promote a safety culture and reduce harm, health care systems are adopting high-reliability organization (HRO) principles. This rapid review synthesizes HRO frameworks, metrics, and implementation effects to help inform health systems' efforts toward becoming HROs.

Methods: Bibliographic databases were searched from 2010 to 2019.

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.

Assessment of Health Information Technology-Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System: A Qualitative Study of Aggregated Root Cause Analysis Data.

Importance: Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged.

Objective: To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system.

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.

A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration.

Background: Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety.

Measuring Council Health to Transform Shared Governance Processes and Practice.

Objective: The aim of this study was to develop a valid, reliable instrument to measure the effectiveness of shared governance councils BACKGROUND: The work of shared governance, that is, the decisions, takes place in its structures, notably, the councils. A literature search yielded no formal instrument for evaluating how these councils function.

Methods: A 4-phase process was used to generate valid items to measure shared governance council effectiveness, including content validity by experts, a pilot for feasibility, a larger pilot for internal consistency, and an exploratory factor analysis to delineate a final instrument.

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.

Assessment of unintended volume loss of six closed system transfer devices.

Introduction: Closed system transfer devices (CSTDs) are used to prepare and administer hazardous drugs. Previous studies have explored the vapor and fluid containment performance of CSTDs. A less obvious consideration is the effect of CSTD use on the intended dose for small volume administrations.

Career Impact of the Chief Resident in Quality and Safety Training Program: An Alumni Evaluation.

Purpose: Most evaluations of quality improvement and patient safety (QI/PS) training programs provide inadequate data on their impact on alumni careers and QI/PS involvement. To address this gap, the authors investigated continued participation in and barriers to QI/PS work, employment, and satisfaction with training among alumni of the Department of Veterans Affairs (VA) Chief Resident in Quality and Safety (CRQS) program.

Method: A cross-sectional, web-based survey was administered in January 2018 to all 238 CRQS program alumni (program years 2009-2017, 54 program sites).

Evolving Sex and Gender in Electronic Health Records.

Development, training, and documentation for the implementation of a self-identified gender identity field in the electronic health record system may improve patient-centered care for transgender and gender nonconforming patients.

Causes of Excess Mortality in Veterans Treated for Posttraumatic Stress Disorder.

Introduction: Published research indicates that posttraumatic stress disorder (PTSD) is associated with increased mortality. However, causes of death among treatment-seeking patients with PTSD remain poorly characterized. The study objective was to describe causes of death among Veterans with PTSD to inform preventive interventions for this treatment population.

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.

Using patient-reported outcomes to understand the effectiveness of guideline-concordant care for post-traumatic stress disorder in clinical practice.

Rationale: Identifying predictors of improvement amongst patients receiving routine treatment for post-traumatic stress disorder (PTSD) could provide information about factors that influence the clinical effectiveness of guideline-concordant care. This study builds on prior work by accounting for delivery of specific evidence-based treatments (EBTs) for PTSD while identifying potential predictors of clinical improvement using patient-reported outcomes measurement.

Method: Our sample consisted of 2 643 US Department of Veterans Affairs (VA) outpatients who initiated treatment for PTSD between 2008 and 2013 and received at least four PTSD checklist (PCL) measurements over 12 weeks.