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VHA National Center for Patient Safety

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Stop the Line for Patient Safety

Stop the Line for Patient Safety. It's everyone's responsibility

"Stop the Line" is an important component of Veterans Health Administration (VHA) culture of safety. The safety and wellbeing of Veterans in our care is the top priority. If someone on the care team sees something that could pose a risk to patient safety, they are empowered to "Stop the Line" until the concern is addressed and can be fixed.

"Stop the Line" is a phrase that comes from the manufacturing industry. Many assembly lines have a big red button on the wall or an emergency pull cord that can be used to stop the assembly process if something goes wrong or could go wrong.

So, what does that mean in a health care setting? It's simple — anyone on VHA's care team can "Stop the Line" if there is a safety concern. We all share a responsibility to keep each other and our Veterans safe, just like they kept us safe. It is always okay to sound the alarm and "Stop the Line".

All members of the VA care team are empowered to "Stop the Line" when they believe something is wrong. Whether it is the surgeon that wants to triple check test results that don't look right, or a member of the housekeeping staff making sure a hospital room is properly cleaned before a newly admitted patient arrives, all members of the care team have the responsibility and the authority to speak up if they see a risk to patient safety. This video shows how any member of the VA care team can "Stop the Line" to ensure patient safety.

"Stop the Line" is one of the principles stressed as part of VHA's Journey to becoming a High Reliability Organization (HRO). In an HRO, all employees, regardless of rank or title, are empowered to speak up in the interest of patient safety. Clinical Team Training (CTT), an integral HRO program, features a section on "Stop the Line" that helps staff members express the 3Ws (What I see, What I'm concerned about, and What I want to happen to keep the patient safe). These questions are core to VHA’s "Stop the Line" process. Clinical Team Training has exposed thousands of VHA employees to this critical HRO tool.

Remember: It is ALWAYS OK to "STOP THE LINE"