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.

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.

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.

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.

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).

Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem.

Objectives: The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention.

Methods: The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken.

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.

The role of the operating room nurse manager in the successful implementation of preoperative briefings and postoperative debriefings in the VHA Medical Team Training Program.

To improve communication within surgical teams, Veterans Health Administration (VHA) implemented a Medical Team Training Program (MTT) based on the principles of crew resource management. One hundred two VHA facilities were analyzed. Nursing leadership participation in the planning stages of the program was compared with outcomes at follow-up.

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.