VHA National Center for Patient Safety

Anuja Vallabh, PGY-1 pharmacy practice resident, in front of her booth focused on “Opioid Safety.”

The Milwaukee VA Medical Center held a patient safety fair March 10 – 11, 2015 to celebrate National Patient Safety Awareness Week.

This year’s theme for the fair was baseball, with the tag-line, “Great Catch for Patient Safety.” Several individuals from a variety of departments partnered with us to develop the patient safety fair’s events.

The first day featured games and booths showcasing The Joint Commission’s National Patient Safety Goals, and other hot topics in patient safety.

Seventeen booths were sponsored by work groups within our organization. Each had been asked to design a game or interactive event in which staff could participate and learn more about a specific topic. The topics were based on vulnerabilities identified from electronic patient event reports (ePERs) that had been submitted at the facility.

Attendees had an opportunity to use safe patient handling equipment, as well as learn about a variety of topics, including: laboratory specimen labeling, clinical alarm management activities, and home oxygen and infusion pump safety.

Tiffany Buckenberger, staff medical technologist and Mary Jo Dejanovich, point-of-care advanced staff specialist, stand in front of their game focused on “Communication of Critical Results.”

In addition to the games, our nursing education department developed a mock patient room simulation activity to challenge staff members’ understanding of specific safety issues. Some features of the room were designed to help keep a Veteran safe; others to put a Veteran at risk. Numerous staff members successfully navigated the challenge and it was quite interesting for all who participated.

Our goal was to have a day of interactive learning events open to all staff members, knowing that each individual can play an important role in keeping our Veterans safe.

More than 200 participants attended this first day of activities − it was well received!

The second day of events featured presentations given to staff and leadership by Gary Sculli, director, NCPS Clinical Team Training Program, focused on “High Reliability in Health Care,” an important aspect of VA’s patient safety program.

His presentations were broadcast locally and to other sites in VISN 12. Attendees had an opportunity to learn about specific “big picture” markers that lead to high reliability in health care, as well as to begin to reflect on what each individual’s role is in achieving this goal.

Melinda Thompson, R.N., discussing insulin safety with Justin Dedecker, administrative officer, anesthesiology department.

Approximately 250 staff members attended the presentations, giving them an opportunity to obtain continuing education credits.

This two-day event could not have been possible without the support of hospital leadership, as well as assistance from the nursing education department, medical media and many other staff members who helped to develop the activities.

It was truly a team effort to make this event happen!

Learn More

A Joint Commission “Library Topic” item:

High-Reliability Health Care: Getting There from Here

Two stories from the NCPS newsletter, Topics in Patient Safety:

Staying in Sync With High-Reliability Organizations

Clinical Team Training: Building High-Reliability in VA Health Care