VHA National Center for Patient Safety
VA's Approach to Patient Safety
Virtually all healthcare organizations prior to the 1999 publication of the Institute of Medicine's landmark report, To Err is Human, engaged in investigations of events that caused harm to patients. Few of these investigations, however, engaged in a systems-based approach to problem solving.
The focus was on individuals and their mistakes, rather than on system level vulnerabilities and events that had combined in an unfortunate sequence to cause an incident to occur. Based on a "name and blame" culture, the emphasis of such investigations was not on prevention, but on individual correction or discipline.
By shifting the goal from eliminating errors to reducing or eliminating harm to patients - through investigating system level vulnerabilities, rather than focusing on individuals - much has been accomplished at VA.
Our goal is simple: The reduction and prevention of inadvertent harm to our patients as a result of their care.
Reducing or eliminating harm to patients is the real key to patient safety. Efforts that focus exclusively on eliminating errors will fail. We'll never eliminate all individual errors. The goal is to design systems that are "fault tolerant," so that when an individual error occurs, it does not result in harm to a patient.
That's why we've based VA's patient safety program on a systems approach to problem solving - focused on prevention, not punishment. We use methods and apply ideas from "high reliability" organizations, such as aviation and nuclear power, to target and eliminate system vulnerabilities.
For instance, the fault-tolerance principle has been used for years by high-reliability organizations when designing systems, and the safety records of such organizations far surpass those of healthcare.
We don't target people; we don't want to participate in the "name and blame" culture of the past. We look for ways to break that link in the chain of events that can create a recurring problem: those underlying systems-based problems that were ignored or unaddressed.
One of the most important ways to do this is to learn from close calls, sometimes called "near misses," which occur at a much higher frequency than actual adverse events. Addressing problems in this way not only results in safer systems, but it also focuses everyone's efforts on continually identifying potential problems and fixing them.
This doesn't mean that VA is a "blame free" organization. We have a system that delineates what type of activities may result in disciplinary action and which do not. Only those events that are intentionally unsafe acts can result in the assignment of blame and punitive action. Intentional unsafe acts, as they pertain to patients, are any events that result from a criminal act, a purposefully unsafe act, or an act related to alcohol or substance abuse on the part of a provider or patient abuse.
The integration of these approaches across the organization creates a level of trust and a focus of efforts that helps perpetuate a culture of safety.
The Just Culture Decision Support Tool provides guidance for a Just Culture.
Read more about VA's approach to patient safety by reading an article written by the NCPS public affairs officer and orginally published online by Federal Practitioner,
Read about a "Culture of Safety and Just Culture" coauthored by a former NCPS director and NCPS' Team Training program manager.