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.

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.

Assessing a National Collaborative Program To Prevent Catheter-Associated Urinary Tract Infection in a Veterans Health Administration Nursing Home Cohort.

OBJECTIVECollaborative programs have helped reduce catheter-associated urinary tract infection (CAUTI) rates in community-based nursing homes. We assessed whether collaborative participation produced similar benefits among Veterans Health Administration (VHA) nursing homes, which are part of an integrated system.SETTINGThis study included 63 VHA nursing homes enrolled in the "AHRQ Safety Program for Long-Term Care," which focused on practices to reduce CAUTI.

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.

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.

Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement.

The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking.

Examining Wrong Eye Implant Adverse Events in the Veterans Health Administration With a Focus on Prevention: A Preliminary Report.

Objective: The study goals were to examine wrong intraocular lens (IOL) implant adverse events in the Veterans Health Administration (VHA), identify root causes and contributing factors, and describe system changes that have been implemented to address this challenge.

Design: This study represents collaboration between the VHA's National Center for Patient Safety (NCPS) and the National Surgery Office (NSO).

Participants: This report includes 45 wrong IOL implant surgery adverse events reported to established VHA NCPS and NSO databases between July 1, 2006, and June 31, 2014.

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.

Background: Preventable adverse events are more likely to occur among older patients because of the clinical complexity of their care. The Veterans Health Administration (VHA) National Center for Patient Safety (NCPS) stores data about serious adverse events when a root cause analysis (RCA) has been performed. A primary objective of this study was to describe the types of adverse events occurring among older patients (age > or = 65 years) in Department of Veterans Affairs (VA) hospitals.

Reduction in patient enrollment in the Veterans Health Administration after media coverage of adverse medical events.

Background: Health care organizations may experience costs associated with preventable adverse events in the form of poor brand image and subsequent patient disenrollment. A retrospective cohort design was used to determine whether media coverage of adverse events that occurred in Veterans Health Administration (VHA) hospitals was associated with subsequent veteran disenrollment.

Methods: Twenty-four newspaper reports of medical adverse events that occurred between 1994 and 1999 within the VHA system were identified.

Using aggregate root cause analysis to improve patient safety.

The authors describe use of aggregate root cause analysis, which provides a systematic process for analyzing high-priority, frequent events.

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety.

Background: In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities.

A Novel Approach: To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering.

James P. Bagian on patient safety initiatives. Interview by Deborah Mears.

James P. Bagian, MD, is director of the Veterans Health Administration (VHA) National Center for Patient Safety (NCPS). With a focus on systems and an emphasis on "prevention not punishment," NCPS is working to improve patient safety, prevent health care errors, and nurture a culture of safety throughout the 173 VHA medical centers.