VHA National Center for Patient Safety

Patient Safety Improvement Corps

Consistent with a positive assessment of NCPS by the Rand Corporation, the Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) selected NCPS to formulate, manage, and implement a multifaceted training program for state health officials and their hospital partners. This landmark interagency agreement between HHS and VA was funded by AHRQ.

The goal was to provide attendees with the skills required to analyze adverse medical events and close calls, as well as to identify the root causes of these events.  Attendees were trained in a broad range of areas, such as:

• How to prepare and implement meaningful corrective actions based on their findings
• How to conduct proactive risk assessments and develop and implement corresponding mitigation initiatives
• How to assess the effectiveness of interventions to better ensure the sustainability of effective interventions that improve patient safety

The program ran from 2003 to 2008:

• Initial training of representatives from all 50 states was completed in 2006.
• Additional training sessions were offered in 2007 and completed in 2008.
  • 22 teams representing a number of states attended these sessions, as well as a groups from Washington D.C. and Puerto Rico.
• More than 300 health care professionals from 210 organizations participated in the program.

Learn More 

Information from AHRQ*†

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