VHA National Center for Patient Safety
Programs and Initiatives
Tool Kits and Cognitive Aids
Human factors-oriented tool kits have been developed by NCPS to promote patient safety while enhancing the user’s awareness of the importance of developing a culture of safety, such as:
A number cognitive aids were also created to support specific program areas and further reduce the risk of causing inadvertent harm to patients, for instance:
Alerts and Other Publications
NCPS publishes safety alerts or advisories on specific issues relating to equipment, medications and procedures that might cause harm to patients. We also base our program on the Patient Safety Improvement Handbook.
Topics in Patient Safety® (TIPS) is a bimonthly newsletter that is also published by NCPS and discusses a wide range of patient safety issues.
- TIPS editions, 2001 to present, are available online
Patient Safety Curriculum
Realizing that the place to begin learning about patient safety is during early training, in 2002, NCPS began working with physicians and patient safety personnel from VA medical centers and affiliated universities to develop and test a patient safety curriculum program for residents. From this, faculty workshops were developed.
Patient Safety Fellowship Program
NCPS and the VA Office of Academic Affiliations (OAA) and have teamed to offer one-year fellowships in patient safety.
The fellowships offer post-residency trained physicians and post-doctoral or post-masters-degree-trained associated health professionals (such as nurses, psychologists, and health care administrators) in-depth education in patient safety practice and leadership.
Contact us via email for further information.
The Daily Plan®
This initiative enhances patient safety by involving patients in their care: A single document is provided to them that outlines what can be expected on a specific day of hospitalization.
A facility can customize the document and include a number of items relevant to care:
- Diagnostic tests
Learn more: The Daily Plan®
Cliniical Team Training Program
The Clinical Team Training program offers an opportunity for clinicians to improve patient safety and job satisfaction by facilitating clear and timely communication through collaborative teamwork in the clinical workplace. Principles of aviation’s Crew Resource Management are introduced in a clinical context to model specific applications in the healthcare environment.
Healthcare Failure Mode and Effect Analysis
Healthcare Failure Mode and Effect Analysis was designed by NCPS specifically for health care, streamlining the hazard analysis steps found in the traditional Failure Mode and Effect Analysis process.
Patient Safety Centers of Inquiry
Managed by NCPS, Patient Safety Centers of Inquiry are located in VA Medical Centers around the country and are focused on researching specific areas of patient safety and providing practical tools to improve patient safety at the bed-side. First funded in 1999, PSCI have made valuable contributions to the improvemen tof patient safety within VHA and beyond.
Our pharmacists support VA Medical Center compliance with Joint Commission National Patient Safety Goals, to include accurate and complete reconciliation of patient’s medications across the continuum of care.
Based on a 2011 study and 2012 trial, they also develop a new standardized patient-centric prescription label that was implimented VA-wide in 2014 to better serve the VA's approximately 4.4 million pharmacy users through redesign of labels affixed to nearly 122 million prescriptions despensed yearly.
Patient Safety Training
For a patient safety program to function effectively, developing a consistent method for training front-line patient safety professionals is critical.
NCPS developed inclusive, one-to-three day training sessions to meet this need. Attendees are presented with specific ways to enhance their patient safety efforts. For instance, they are offered guidance on how best to develop and implement a root cause analysis team
VA employees can contact us via email for further information.
Product Recall Office
Located within NCPS, the VHA’s Product Recall Office is tasked to manage recalls of all medical devices and products initiated by manufactures or the FDA that are applicable to VHA. In some cases, recalls can also orignate within VHA.
Recall staff members evaluate the impact of a recall and then communicate corrective actions to be taken by staff at the appropriate VHA facilities. Depending on the nature of the recall, and the potential harm to patients, this can include patient notification and may also lead to the development by NCPS of a VHA patient safety alert or advisory.
- VHA Directive 1068: Recall of Defective Medial Devices and Medical Products, Including Food and Food Products
Pulling an unsafe product off the shelf and returning it to a supplier is one important way to safeguard the life or health of a patient.
Previous Initiatives and Actions
Prevention of Retained Surgical Items
NCPS collaborated with the VA Office of Patient Care Services to draft the Prevention of Retained Surgical Items Directive. The directive was pilot-tested at six VA facilities. It focuses on wound exploration, counting items, and radiography, as well as the basic decision-making process to follow when a count is wrong.
Emergency Airway Management
NCPS also developed a directive to improve emergency airway management outside the operating room, in collaboration with VA Patient Care Services and field clinical representatives. VA policy now requires airway management techniques that address both equipment and practitioner requirements in airway management skills.
Patient Safety Improvement Corps
In 2003, NCPS partnered with the Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) to launch a national Patient Safety Improvement Corps.
NCPS formulated, managed and implemented a comprehensive training program for state health officials and their selected hospital partners; AHRQ funded it. The program ran from 2003 to 2008. More than 300 health care professionals from 210 organizations participated in the program.
Patient Safety Initiative (PSI)
The Patient Safety Initiative was established to stimulate creative approaches to complex patient safety issues, and many successful projects have been funded in the first two years of the program.
- Seventy-eight proposals have been funded since fiscal year 2006.
VA patient safety professionals have used PSI as an opportunity to develop projects with a demonstrable impact on their patient safety programs; projects with well-defined measures and strong rationales.
Patient Safety Design Challenge
The initiative provided patient safety managers an opportunity to create a positive impact on design standards VHA-wide. Teams were recognized the year following their submissions.
During two challenges, held 2006 and 2008, five teams were recognized for taking a creative approach to design.
Two categories were offered:
- Architecture and design of medical care and treatment spaces
- Equipment layout, design and procurement
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