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Objective: To assess Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) as performance measures using Veterans Administration hospitalization data. DATA SOURCES STUDY SETTING: Nine years (1997-2005) of all Veterans Health Administration (VA) administrative hospital discharge data.Study Design: Retrospective analysis using diagnoses and procedures to derive annual rates and standard errors for 13 PSIs.Data Collection/extraction Methods: For either hospitals or hospital networks (Veterans Integrated Service Networks [VISNs]), we calculated the percentages whose PSI rates were consistently high or low across years, as well as 1-year lagged correlations, for each PSI. We related our findings to the average annual number of adverse events that each PSI represents. We also assessed time trends for the entire VA, by VISN, and by hospital.Principal Findings: PSI rates are more stable for VISNs than for individual hospitals, but only for those PSIs that reflect the most frequent adverse events. Only the most frequent PSIs yield significant time trends, and only for larger systems.Conclusions: Because they are so rare, PSIs are not reliable performance measures to compare individual hospitals. The most frequent PSIs are more stable when applied to hospital networks, but needing large patient samples nullifies their potential value to managers seeking to improve quality locally or to patients seeking optimal care. [ABSTRACT FROM AUTHOR]

Objectives: Resident and fellow engagement in patient safety event investigations (PSEIs) can benefit both the clinical learning environment's ability to improve patient care and learners' problem-solving skills. The goals of this collaborative were to increase resident and fellow participation in these investigations and improve PSEI quality., Methods: This collaborative involved 18 sites-8 sites that had participated in a similar previous collaborative (cohort I) and 10 "new" sites (cohort II). The 18-month collaborative included face-to-face and virtual learning sessions, check-ins, and coaching calls. A validated assessment tool measured PSEI quality, and sites tracked the percentage of first-year residents and fellows included in a PSEI., Results: Sixteen of the 18 sites completed the 18-month collaborative. Baseline was no first-year resident or fellow participation in a PSEI. Among these 16 clinical learning environments, 1237 early learners participated in a PSEI by the end of the collaborative. Six of these 16 sites (38%) reached the goal of 100% participation of first-year residents and fellows. As a percentage of total first-year residents and fellows, larger institutions had less resident and fellow participation. Six of the 9 cohort II sites submitted PSEIs for independent review at 6 months and again at the end of the collaborative. The PSEI quality scores increased from 5.9 ± 1.8 to 8.2 ± 0.8 ( P ≤ 0.05)., Conclusions: It is possible to include all residents and fellows in PSEIs. Patient safety event investigation quality can improve through resident and fellow participation, use of standardized processes during training and investigations, and review of PSEI quality scores with a validated tool., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Previous studies have demonstrated that residents participating in patient safety event investigations become more engaged in future patient safety activities. Currently, there is a gap in resident participation in patient safety event analyses. The objective was to develop and implement a sustainable, faculty-led curriculum for resident participation in patient safety event investigations and to evaluate resident perceptions of the training at least one year following completion of the training. One hundred sixty-five residents from three specialties participated in a formal RCA 2 training curriculum from 2013 to 2019. In November 2019, the same residents were asked to complete a survey which examined their perception of the training including the tools and techniques such as event mapping, cause-and-effect diagramming, and developing action plans for solving problems and unsafe conditions. The survey response rate was 36 % (60/165). Sixty-three percent (38/60) of the residents responding to the survey believed that RCA 2 training should be provided to all residents. Former residents rated the RCA 2 training tools and skills favorably, 3.6 median score (3.5-3.7, 95 % C.I.). Forty-eight percent of responding residents (29/60) believed that the previous RCA 2 training improved the way they identify and solve problems. The curriculum and faculty development program provides an effective intervention to address the current, identified gaps in patient safety in graduate medical education., Competing Interests: The authors have no conflicts of interest., (© 2023 The Authors. Published by Elsevier Inc.)

Objective: To determine the extent of implementation, completeness, and accuracy of Structured and Codified SIG (S&C SIG) directions on electronic prescriptions (e-prescriptions)., Materials and Methods: A retrospective analysis of a random sample of 3.8 million e-prescriptions sent from electronic prescribing (e-prescribing) software to outpatient pharmacies in the United States between 2019 and 2021. Natural language processing was used to identify direction components, including action verb, dose, frequency, route, duration, and indication from free-text directions and were compared to the S&C SIG format. Inductive qualitative analysis of S&C direction identified error types and frequencies for each component., Results: Implementation of the S&C SIG format in e-prescribing software resulted in 32.4% of e-prescriptions transmitted with these standardized directions. Directions using the S&C SIG format contained a greater percentage of each direction component compared to free-text directions, except for the indication component. Structured and codified directions contained quality issues in 10.3% of cases., Discussion: Expanding adoption of more diverse direction terminology for the S&C SIG formats can improve the coverage of directions using the S&C SIG format. Building out e-prescribing software interfaces to include more direction components can improve patient medication use and safety. Quality improvement efforts, such as improving the design of e-prescribing software and auditing for discrepancies, are needed to identify and eliminate implementation-related issues with direction information from the S&C SIG format so that e-prescription directions are always accurately represented., Conclusion: Although directions using the S&C SIG format may result in more complete directions, greater adoption of the format and best practices for preventing its incorrect use are necessary., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To determine the variability of ingredient, strength, and dose form information from drug product descriptions in real-world electronic prescription (e-prescription) data., Materials and Methods: A sample of 10 399 324 e-prescriptions from 2019 to 2021 were obtained. Drug product descriptions were analyzed with a named entity extraction model and National Drug Codes (NDCs) were used to get RxNorm Concept Unique Identifiers (RxCUI) via RxNorm. The number of drug product description variants for each RxCUI was determined. Variants identified were compared to RxNorm to determine the extent of matching terminology used., Results: A total of 353 002 unique pairs of drug product descriptions and NDCs were analyzed. The median (1st-3rd quartile) number of variants extracted for each standardized expression in RxNorm, was 3 (2-7) for ingredients, 4 (2-8) for strength, and 41 (11-122) for dosage forms. Of the pairs, 42.35% of ingredients (n = 328 032), 51.23% of strengths (n = 321 706), and 10.60% of dose forms (n = 326 653) used matching terminology, while 16.31%, 24.85%, and 13.05% contained nonmatching terminology, respectively., Discussion: A wide variety of drug product descriptions makes it difficult to determine whether 2 drug product descriptions describe the same drug product (eg, using abbreviations to describe an active ingredient or using different units to represent a concentration). This results in patient safety risks that lead to incorrect drug products being ordered, dispensed, and used by patients. Implementation and use of standardized terminology may reduce these risks., Conclusion: Drug product descriptions on real-world e-prescriptions exhibit large variation resulting in unnecessary ambiguity and potential patient safety risks., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: A proactive risk assessment using the Healthcare Failure Mode and Effect Analysis (HFMEA) process was completed on the intraocular lens (IOL) selection and implantation process to analyze system vulnerabilities that could cause patient harm. The three largest ophthalmology clinics based on patient surgical volume were studied in the analysis. The analysis included in-clinic eye measurements needed for IOL selection through the actual implantation of the lens in the operating room., Methods: The HFMEA process was used for the analysis. A detailed process and subprocess diagram was created through interviews and observations. A multidisciplinary team met 12 times over a 14-week period, evaluating 170 discrete process and subprocess steps and identifying 177 failure modes and 75 failure mode causes for analysis., Results: A high degree of process variability and lack of a robust quality assurance process was found. Areas for improvement included reducing variability between and within clinics, reducing variability in processes used by surgeons, modifying equipment and software to better support the work processes, and implementing a quality assurance program requiring observation of staff performing their routine work as opposed to relying on self-reports of quality metrics., Conclusion: The HFMEA process provided a more complete understanding of all of the processes associated with cataract surgery. This allowed for the identification of a variety of risk factors to patient safety that had not previously been identified by the more traditional reactive analysis methods, which tend to focus only on vulnerabilities identified by a specific event., (Copyright © 2019. Published by Elsevier Inc.)

Background: This paper describes the design of a multifunction alerting display for intraoperative anesthetic care. The design was inspired by the multifunction primary flight display used in modern aviation., Results: The display retrieves live data from multiple sources; the physiologic monitors, the anesthesia information management system, the laboratory values and comorbidities from patient's problem summary list, medical history or history & physical. This information is integrated into a display composed of readily identifiable icons of organ systems, which are color coded to signify normal range, marginal range, abnormal range (by green, yellow, red respectively) and orange outlines for comorbidities/risk factors. There are dozens of text alerts, which can be presented as black text (informational), red text (important information) and red scrolling text (highest importance information). The alerts are derived from current standards in the literature and some involve complex calculations being conducted in the background., Conclusions: The goal of such a system is to improve the quality and safety of anesthetic care by providing enhanced situational awareness in a fashion analogous to the "glass cockpit" and its primary flight display which has improved aviation safety.

Effective teamwork and communication can decrease medical errors in environments where the culture of safety is enhanced. Health care can benefit from programs that are based on teamwork, as in other high-stress industries (e.g., aviation), with crew resource management programs, simulator use, and utilization of checklists. Medical team training (MTT) with a strong leadership commitment was used at our institution to focus specifically on creating open, yet structured, communication in operating rooms. Training included the 3 phases of the World Health Organization protocol to organize communication and briefings: preoperative verification, preincision briefing, and debriefing at or near the end of the surgical case. This training program led to measured improvements in job satisfaction and compliance with checklist tasks, and identified opportunities to improve training sessions. MTT provides the potential for sustainable change and a positive impact on the environment of the operating room.

The quality of care delivered by orthopedic surgeons continues to grow in importance. Multiple orthopedic programs, organizations, and committees have been created to measure the quality of surgical care and reduce the incidence of medical adverse events. Structured root cause analysis and actions (RCA2) has become an area of interest. If performed thoroughly, RCA2 has been shown to reduce surgical errors across many subspecialties. The Accreditation Council for Graduate Medical Education has a new mandate for programs to involve residents in quality improvement processes. Resident engagement in the RCA2 process has the dual benefit of educating trainees in patient safety and producing meaningful changes to patient care that may not occur with traditional quality improvement initiatives. The RCA2 process described in this article can provide a model for the development of quality improvement programs. In this article, the authors discuss the history and methods of the RCA2 process, provide a stepwise approach, and give a case example. [Orthopedics. 2017; 40(4):e628-e635.]., (Copyright 2017, SLACK Incorporated.)

Objective: To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information., Design: Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group., Setting: Large teaching hospital., Participants: Findings of a literature review were presented to orthopaedic residents, epidemiologists, orthopaedic surgeons and patient safety experts in face-to-face meetings, during which we developed and refined the contents of a resident handoff tool. The tool was tested in an orthopaedic trauma service and its impact on adverse events was evaluated through a chart review. The handoff tool was developed and refined during the face-to-face meetings and a pilot implementation. Adverse event data were collected on 127 patients (n = 67 baseline period; n = 60 test period)., Intervention: A handoff tool for use by orthopaedic residents., Main Outcome Measurements: Adverse events in patients handed off by orthopaedic trauma residents., Results: After controlling for age, gender and comorbidities, testing resulted in fewer events per person (25-27% reduction; P < 0.10)., Conclusions: Preliminary evidence suggests that our resident handoff tool may contribute to a decrease in adverse events in orthopaedic patients., (© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

In the past 15 years, there has been growing recognition that improving patient safety must be more systems based and sophisticated than the traditional approach of simply telling health care providers to "be more careful." Drawing from his own experience, the author discusses barriers to systems-based patient safety initiatives and emphasizes the importance of overcoming those barriers. Physicians may be slow to adopt standardized patient safety initiatives because of a resistance to standardization, but faculty in training institutions have a responsibility to model safe, effective, systems-based approaches to patient care in order to instill these values in the residents they teach. Importantly, graduate medical education (GME) is well positioned to influence not only how future physicians provide care to patients but also how today's physicians and health care systems improve patient safety and care. The necessary systems-based knowledge and skills are rooted in both understanding and proficiently identifying threats to patient safety, their underlying causes, the development and implementation of effective countermeasures, and the measurement of whether the threat has been successfully addressed. This knowledge and its application is notably absent in the operation of most institutions that sponsor GME training programs in terms of didactic instruction and everyday demonstrated proficiency. Most important of all, faculty must model the behavior and competencies that are desirable in future physicians and not fall into the trap of the "do as I say, not as I do" mentality, which can have a corrosive deleterious effect on the next generation of physicians.

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time. This article presents data that show one such strategy, called the Effective Followership Algorithm, offering statistically significant improvements in team communication across the professional continuum from students and residents to experienced clinicians., (© 2015 American Society for Healthcare Risk Management of the American Hospital Association.)

The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties and its member boards introduced the six domains of physician competency in 1999. This initiated a national dialogue concerning the elements of competency of the physician, and incorporation of these elements into the framework of evaluation of residents and fellows, as well as the educational programs within which they are trained. The next step in this process will be the ACGME's Next Accreditation System, which the authors describe in this commentary. Recognizing that there are already developments in the assessment of medical education that will influence future models of accreditation, the authors consider some of these innovations and discuss how they may shape the next accreditation system after the Next Accreditation System.

Background: This is the first study of suicide attempts and completions in the emergency department (ED) in a large national medical system., Methods: All root cause analysis (RCA) reports completed of suicides and suicide attempts that occurred in ED in the Veterans Health Administration between 1 December 1999 and 31 December 2009 were reviewed. The method, location, anchor point for hanging and implement for cutting as well as the root causes were categorised., Results: Ten per cent of all RCA reports of suicides and suicide attempts that occur within the hospital occur in the ED. Hanging, cutting and strangulation were the most common methods. The most common anchor point for hanging was doors, and the most common implement for cutting was a razor blade. In eight of the 10 cases of cutting, the implement was brought into the ED. The most common root causes were problems communicating risk and being short-staffed., Conclusions: Based on these results the following recommendations are made for helping to reduce suicide attempts in the ED: (1) use a systematic protocol and checklist to review mental health holding areas periodically in the ED for suicidal hazards; (2) develop and implement specialised protocols for suicidal patients that include continuous observation when possible; (3) conduct thorough contraband searches with suicidal patients; (4) designate specialised holding areas, when practically possible, for suicidal patients that are free of anchor points for hanging, sharps and medications, and medical equipment; and are isolated from exits to reduce the risk of elopement.

Objective: To determine whether there is an association between the Veterans Health Administration Medical Team Training (MTT) program and surgical morbidity., Design, Setting, and Participants: A retrospective health services study was conducted with a contemporaneous control group. Outcome data were obtained from the Veterans Health Administration Surgical Quality Improvement Program. The analysis included aggregated measures representing 119,383 sampled procedures from 74 Veterans Health Administration facilities that provide care to veterans., Main Outcome Measures: The primary outcome measure was the rate of change in annual surgical morbidity rate 1 year after facilities enrolled in the MTT program as compared with 1 year before and compared with the non-MTT program sites., Results: Facilities in the MTT program (n = 42) had a significant decrease of 17% in observed annual surgical morbidity rate (rate ratio, 0.83; 95% CI, 0.79-0.88; P = .01). Facilities not trained (n = 32) had an insignificant decrease of 6% in observed morbidity (rate ratio, 0.94; 95% CI, 0.86-1.05; P = .11). After adjusting for surgical risk, we found a decrease of 15% in morbidity rate for facilities in the MTT program and a decrease of 10% for those not yet in the program. The risk-adjusted annual surgical morbidity rate declined in both groups, and the decline was 20% steeper in the MTT program group (P = .001) after propensity-score matching. The steeper decline in annual surgical morbidity rates was also observed in specific morbidity outcomes, such as surgical infection., Conclusion: The Veterans Health Administration MTT program is associated with decreased surgical morbidity.

Objective: To describe incorrect surgical procedures reported from mid-2006 to 2009 from Veterans Health Administration medical centers and build on previously reported events from 2001 to mid-2006., Design: Retrospective database review., Setting: Veterans Health Administration medical centers., Interventions: The Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety., Main Outcome Measures: The categories were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm., Results: Our review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P = .02). Reported close calls increased from 1.97 to 3.24 per month (P ≤ .001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%)., Conclusions: The rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed.

Background: The Veterans Health Administration has had a comprehensive patient safety program since 1999 that includes conducting root cause analysis (RCA) of adverse medical events. Improving the quality and timeliness of the RCAs at the local level has been a continual challenge., Methods: We initiated a non-monetary program called the Cornerstone Award into our patient safety reporting system to recognise facilities conducting high-quality and timely RCAs containing deterministic corrective actions that are implemented and evaluated for effectiveness., Results: Since the Cornerstone Program began in 2008, the per cent of RCAs completed in a time-critical manner (≤45 days) has increased from an average of 52% pre-Cornerstone to an average of 94% post-Cornerstone. The per cent of action plans with stronger deterministic actions and outcomes has increased from an average of 34% pre-Cornerstone to an average of 70% post-Cornerstone., Discussion: Implementing a non-monetary recognition award that was tied to specific improvement goals greatly improved the timeliness and quality of the RCA reports in the Veterans Health Administration System.

Background: : There is currently an incomplete understanding of adverse events related to electroconvulsive therapy (ECT) treatments. Much of the published literature is based either on a limited number of ECT providers or reports not representative of modern ECT practice., Methods: : We searched the Veterans Affairs (VA) National Center for Patient Safety database for reports of adverse events related to ECT. The type and the cause of the events were determined and aggregated. The number of ECT treatments given in the VA was used to develop estimated rates of mortality associated with ECT., Results: : There were no deaths associated with ECT reported in any VA hospital between 1999 and 2010. Based on the number of treatments given, we estimate the mortality rate associated with ECT as less than 1 death per 73,440 treatments. The most common reported adverse events related to ECT were injury to the mouth (including dental and tongue injury) and problems related to paralysis., Conclusions: : Based on this VA data, ECT may be safer than is widely reported. The reported adverse events were generally rare and typically minor in severity. Simple steps may possibly result in further enhancements to ECT safety.

Perceptions of organizational commitment to safety differ between the operating rooms in high- and medium-complexity facilities of the Veterans Health Administration (VHA). The purpose of this study was to see whether medical team training (MTT) reduced this difference. The Safety Attitudes Questionnaire was administered before and at the completion of a MTT program. The study population consisted of respondents working in the operating room. Responses to the 7 safety climate items were analyzed using nonparametric tests. Before MTT, respondents working at medium-complexity facilities had more favorable perceptions of knowledge of proper channels and encouragement by colleagues to report safety concerns than respondents who work at high-complexity facilities. At completion, there was no difference in perceptions between respondents working at high- and medium-complexity facilities for these items. The VHA MTT program improved perceptions at both high- and medium-complexity facilities and eliminated differences present at baseline.

Context: Many safety initiatives have been transferred successfully from commercial aviation to health care. This article develops a typology of aviation safety initiatives, applies this to health care, and proposes safety measures that might be adopted more widely. It then presents an economic framework for determining the likely costs and benefits of different patient safety initiatives., Methods: This article describes fifteen examples of error countermeasures that are used in public transport aviation, many of which are not routinely used in health care at present. Examples are the sterile cockpit rule, flight envelope protection, the first-names-only rule, and incentivized no-fault reporting. It develops a conceptual schema that is then used to argue why analogous initiatives might be usefully applied to health care and why physicians may resist them. Each example is measured against a set of economic criteria adopted from the taxation literature., Findings: The initiatives considered in the article fall into three themes: safety concepts that seek to downplay the role of heroic individuals and instead emphasize the importance of teams and whole organizations; concepts that seek to increase and apply group knowledge of safety information and values; and concepts that promote safety by design. The salient costs to be considered by organizations wishing to adopt these suggestions are the compliance costs to clinicians, the administration costs to the organization, and the costs of behavioral distortions., Conclusions: This article concludes that there is a range of safety initiatives used in commercial aviation that could have a positive impact on patient safety, and that adopting such initiatives may alter the safety culture of health care teams. The desirability of implementing each initiative, however, depends on the projected costs and benefits, which must be assessed for each situation., (© 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.)

While suicide among recently returned veterans is of great concern, it is a relatively rare occurrence within individual hospitals and clinics. Root cause analysis (RCA) generates a detailed case report that can be used to identify system-based vulnerabilities following an adverse event. Review of a national database of RCA reports may identify common vulnerabilities and assist in the development of more robust prevention strategies. Our objective was to identify and compare common themes among reports of suicide among veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) in the Veterans Affairs system. Common themes among root causes of suicide as identified in RCA reports were collected and compared as the primary outcome--systematic vulnerabilities. Actions recommended within the reports were coded as the secondary outcome--prevention strategies. Fifty-one RCA reports of OIF/OEF suicides were identified by our search. Coding generated 16 common categories among 132 root causes, and 13 categories among 108 recommended actions. Assessment of suicidal risk, coordination of care, timely access to care, and communication among providers were the most common root causes. Actions identified by RCA teams to reduce suicide included improving referral processes, staff education in suicide assessment, and follow-up with suicidal veterans. Review of multiple RCA reports can identify organizational vulnerabilities detected at the local level that may be applicable system wide. Attention to improving suicide assessment, coordination of care, and timely access may have the largest impact on reducing suicide among OIF/OEF veterans., (© 2011 The American Association of Suicidology.)

This study explores the effect of facility complexity on operating room (OR) caregiver perceptions of safety climate in the Veterans Health Administration (VHA). Facility complexity is a standardized score based on volume, risk, teaching, research, and intensive care unit capability. The Safety Attitudes Questionnaire was administered at 34 VHA hospitals. The authors performed analysis of variance on safety climate item scores by facility complexity and Bonferroni post hoc probes. Caregivers at high-complexity facilities were significantly less likely to agree that "Medical errors are handled appropriately in this hospital" than caregivers at medium-complexity facilities. Caregivers at high-complexity facilities were significantly more likely to agree that "I know the proper channels to direct questions regarding patient safety in the ORs here" than caregivers at medium-complexity facilities. Differences in caregiver perceptions of safety climate by facility complexity are present. Awareness of these differences can help when facilities implement surgical safety procedures.

Background: The purpose of this study was to examine the outcomes of checklist-driven preoperative briefings and postoperative debriefings during the Veterans Health Administration (VHA) medical team training program., Methods: A briefing score (1, never started; 2, started then discontinued; 3, maintained on original targeted cases; 4, expanded to other services; 5, briefing all cases, all services) was established at 10.1 ± .3 months after introduction of the checklist. Outcomes included antibiotic and deep venous thrombosis prophylaxis compliance rates before and after use of the checklist., Results: Antibiotic (97.0% ± .1% vs 92.1% ± 1.5%; P = .01) and deep venous thrombosis (95.7% ± .8% vs 85.1% ± 4.6%; P = .05) prophylaxis compliance rates were higher after initiation of a surgical checklist., Conclusions: Checklist-driven preoperative briefings and postoperative debriefings are associated with improvements in patient safety for surgical patients., (Published by Elsevier Inc.)

Context: There is insufficient information about the effectiveness of medical team training on surgical outcomes. The Veterans Health Administration (VHA) implemented a formalized medical team training program for operating room personnel on a national level., Objective: To determine whether an association existed between the VHA Medical Team Training program and surgical outcomes., Design, Setting, and Participants: A retrospective health services study with a contemporaneous control group was conducted. Outcome data were obtained from the VHA Surgical Quality Improvement Program (VASQIP) and from structured interviews in fiscal years 2006 to 2008. The analysis included 182,409 sampled procedures from 108 VHA facilities that provided care to veterans. The VHA's nationwide training program required briefings and debriefings in the operating room and included checklists as an integral part of this process. The training included 2 months of preparation, a 1-day conference, and 1 year of quarterly coaching interviews, Main Outcome Measure: The rate of change in the mortality rate 1 year after facilities enrolled in the training program compared with the year before and with nontraining sites., Results: The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P = .01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P = .59). The risk-adjusted mortality rates at baseline were 17 per 1000 procedures per year for the trained facilities and 15 per 1000 procedures per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 procedures per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in the risk-adjusted surgical mortality rate was about 50% greater in the training group (RR,1.49; 95% CI, 1.10-2.07; P = .01) than in the nontraining group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program, a reduction of 0.5 deaths per 1000 procedures occurred (95% CI, 0.2-1.0; P = .001)., Conclusion: Participation in the VHA Medical Team Training program was associated with lower surgical mortality.

To improve communication within surgical teams, Veterans Health Administration (VHA) implemented a Medical Team Training Program (MTT) based on the principles of crew resource management. One hundred two VHA facilities were analyzed. Nursing leadership participation in the planning stages of the program was compared with outcomes at follow-up. Nurse manager participation in planning was associated with higher rates of implementation of preoperative briefing and postoperative debriefing. Nurse managers are a critical component in the planning phase of team training programs focused on OR clinical staff., (Published by Elsevier Inc.)

Background: Communication is problematic in healthcare. The Veterans Health Administration is implementing Medical Team Training. The authors describe results of the first 32 of 130 sites to undergo the programme. This report is unique; it provides aggregate results of a crew resource-management programme for numerous facilities., Methods: Facilities were taught medical team training and implemented briefings, debriefings and other projects. The authors coached teams through consultative phone interviews over a year. Implementation teams self-reported implementation and rated programme impact: 1='no impact' and 5='significant impact.' We used logistic regression to examine implementation of briefing/debriefing., Results: Ninety-seven per cent of facilities implemented briefings and debriefings, and all implemented an additional project. As of the final interview, 73% of OR and 67% of ICU implementation teams self-reported and rated staff impact 4-5. Eighty-six per cent of OR and 82% of ICU implementation teams self-reported and rated patient impact 4-5. Improved teamwork was reported by 84% of OR and 75% of ICU implementation teams. Efficiency improvements were reported by 94% of OR implementation teams. Almost all facilities (97%) reported a success story or avoiding an undesirable event. Sites with lower volume were more likely to conduct briefings/debriefings in all cases for all surgical services (p=0.03)., Conclusions: Sites are implementing the programme with a positive impact on patients and staff, and improving teamwork, efficiency and safety. A unique feature of the programme is that implementation was facilitated through follow-up support. This may have contributed to the early success of the programme.

The quality of teamwork among health care professionals is known to affect patient outcomes. In the OR, surgeons report more favorable perceptions of communication during procedures and of teamwork effectiveness than do nurses. We undertook a quality improvement project in the Veterans Health Administration to confirm reported teamwork differences between perioperative nurses and surgeons and to examine the implications of these differences for improving practice patterns in the OR. The Safety Attitudes Questionnaire, which measures safety culture, including the quality of communication and collaboration among health care providers who routinely work together, was administered in 34 hospitals. Perioperative nurses who participated in the survey rated teamwork higher with other nurses than with surgeons, but surgeons rated teamwork high with each other and with nurses. On five of six communication and collaboration items, surgeons had a significantly more favorable perception than did perioperative nurses. To increase the likelihood of success when implementing the use of checklist-based crew resource management tools, such as the World Health Organization's Surgical Safety Checklist, project leaders should anticipate differences in perception between members of the different professions that must be overcome if teamwork is to be improved., (Copyright 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Achieving a culture of safety is believed to be an important mechanism for improving patient safety. The Safety Attitudes Questionnaire (SAQ) measures provider perceptions of patient safety culture across six domains; higher scores denote more positive perceptions. Although professional differences on the SAQ have been explored, sex differences have not., Methods: The SAQ was administered to operating room (OR) care givers at nine Department of Veterans Affairs hospitals. We determined the mean domain scores by care giver profession and sex, used analysis of variance to compare mean scores across professions, used t tests to compare mean scores between sexes and created regression models of the six patient safety domains., Results: The SAQ was completed by 187 OR care givers. Older care givers were significantly more likely to report favourable perceptions of teamwork climate; surgeons were significantly more likely to report favourable perceptions of working conditions; anaesthesia providers were significantly more likely to report favourable perceptions of stress recognition but also less favourable perceptions of safety climate. Women were significantly more likely to report less favourable perceptions of job satisfaction and working conditions., Conclusion: This pilot study confirms previously reported profession differences in OR care giver patient safety attitudes. We also found previously unreported sex differences. Educational efforts designed to enhance patient safety should be designed so that they address such differences.

Background: Approximately 1,500 suicides take place in inpatient hospital units in the United States each year. This study, the first of its kind, examines the implementation and effectiveness of using a standardized checklist for mental health units to improve patient safety in a large health care system., Methods: In 2006 a Department of Veterans Affairs (VA) committee was charged with developing a checklist to explicitly identify environmental hazards on acute mental health units treating suicidal patients. The committee developed both general guidelines to be applied to all areas of the psychiatric unit and detailed guidelines for specific rooms, such as bathrooms, bedrooms, and seclusion rooms., Results: Some 113 VA facilities used the Mental Health Environment of Care Checklist to evaluate their mental health units, identifying and rating 7,642 hazards. At the end of the first year of the project, because of the checklist, 5,834 (76.3%) of these hazards had been abated by facilities; approximately 2% were identified as critical hazards, and another 27% were rated as serious. The most common hazard was anchor points for hanging, followed by material that could be used as a weapon against staff or other patients and problems keeping patients in the secured unit environment. Anchor points had the greatest risk-level classification, followed by suffocation risk and poison risk. High-risk locations included bedrooms and bathrooms., Discussion: Anchor points represented almost 44% of the total number of identified hazards, and materials that could be used as weapons comprised nearly 14% of the total. It is critical to review the mental health environment of care with an eye for these potential weapons. The checklist and resulting mitigations of hazards represent steps toward the overall goal of preventing inpatient suicides.

Context: Unplanned readmission within 30 days of discharge is an indicator of hospital quality., Purpose: We wanted to determine whether older rural veterans who were enrolled in the VA had different rates of unplanned readmission to VA or non-VA hospitals than their urban counterparts., Methods: We used the combined VA/Medicare dataset to examine 3,513,912 hospital admissions for older veterans that occurred in VA or non-VA hospitals between 1997 and 2004. We calculated 30-day readmission rates and odds ratios for rural and urban veterans, and we performed a logistic regression analysis to determine whether living in a rural setting or initially using the VA for hospitalization were independent risk factors for unplanned 30-day readmission, after adjusting for age, sex, length of stay of the index admission, and morbidity., Findings: Overall, rural veterans had slightly higher 30-day readmission rates than their urban counterparts (17.96% vs 17.86%; OR 1.006, 95% CI: 1.0004, 1.013). For both rural- and urban-dwelling veterans, readmission after using a VA hospital was more common than after using a non-VA hospital (20.7% vs 16.8% for rural veterans, 21.2% vs 16.1% for urban veterans). After adjusting for other variables, readmission was more likely for rural veterans and following admission to a VA hospital., Conclusions: Our findings suggest that VA should consider using the unplanned readmission rate as a performance metric, using the non-VA experience of veterans as a performance benchmark, and helping rural veterans select higher performing non-VA hospitals.

Objective: To describe incorrect surgical procedures reported from Veterans Health Administration (VHA) Medical Centers from 2001 to mid-2006 and provide proposed solutions for preventing such events., Design: Descriptive study., Setting: Veterans Health Administration Medical Centers., Participants: Veterans of the US Armed Forces., Interventions: The VHA instituted an initial directive, "Ensuring Correct Surgery and Invasive Procedures," in January 2003. The directive was updated in 2004 to include non-operating room (OR) invasive procedures and incorporated requirements of The Joint Commission Universal Protocol for preventing wrong-site operations., Main Outcome Measures: The categories included 5 incorrect event types (wrong patient, side, site, procedure, or implant), major or minor surgical procedures, location in or out of the OR, therapeutic or diagnostic events, adverse event or close call, inpatient or ambulatory events, specialty department, body segment, and severity and probability of harm., Results: We reviewed 342 reported events (212 adverse events and 130 close calls). Of these, 108 adverse events (50.9%) occurred in an OR, and 104 (49.1%) occurred elsewhere. When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2%] each), whereas orthopedics was second to ophthalmology for number of reported adverse events occurring in the OR. Pulmonary medicine cases (such as wrong-side thoracentesis) and wrong-site cases (such as wrong spinal level) were associated with the most harm. The most common root cause of events was communication (21.0%)., Conclusions: Incorrect ophthalmic and orthopedic surgical procedures appear to be overrepresented among adverse events occurring in ORs. Outside the OR, adverse events by invasive radiology were most frequently reported. Incorrect surgical procedures are not only an OR challenge but also a challenge for events occurring outside of the OR. We support earlier communication based on crew resource management to prevent surgical adverse events.

Background: Suicide is the eleventh leading cause of death in the United States. Approximately 1,500 suicides occur in inpatient hospital units in the United States each year. In an attempt to determine the methods and environmental factors involved in inpatient suicide and suicide attempts in Department of Veterans Affairs (VA) hospitals, all root cause analysis (RCA) reports of inpatient suicides and suicide attempts submitted to the VA National Center for Patient Safety (NCPS) before June 2006 were reviewed., Methods: VA medical centers are required to conduct RCAs on all inpatient suicides and report all suicides and serious suicide attempts to the NCPS. All reports of inpatient suicide and suicide attempts submitted between December 1999 and June 2006 were reviewed, including methods and environmental factors involved in the events., Results: A total of 185 inpatient suicide and suicide attempts were reported; 42 were completed suicides and 143 were suicide attempts. Approximately 52% of the total number of events occurred while the patient was on an inpatient psychiatry unit. Three methods of self harm--intentional drug overdose, cutting with a sharp object, and hanging--accounted for 71% of the total number of events. Doors and wardrobe cabinets accounted for 41% of the anchor points when hanging was the method of self-harm. For suicide attempts involving cutting behaviors, razor blades accounted for 37% of the total number of events; 57% of jumping-related events occurred from balconies and walkways., Conclusions: Careful review of RCA reports of inpatient suicide has resulted in focused interventions to improve patient care and patient safety in VA medical centers, including a comprehensive environment-of-care checklist for reviewing inpatient psychiatry units.

Context: Previous studies have compared measures of patient safety for veterans using the VA system to the general population. Discrepancies in the results of those studies suggest that the choice of an appropriate comparison group is critical for accurate interpretation of results and for determining whether to take actions to address findings. We explored another method of providing consumer information by comparing the experiences of VA enrolled patients who received care in the VA to those who received care outside the VA system., Objective: For male veterans living in New York State and enrolled in the VA healthcare system, to determine (a) whether those who obtain care outside the VA system experience different measures of patient safety than those treated within the VA system, and (b) whether cross-system comparisons of measures of patient safety among older veterans reflect those of the full age spectrum., Design: Retrospective cohort analysis., Setting: All VA and non-VA hospitals in New York State., Patients: 353,570 male New York State residents who were enrolled in the VA system in 1998, 1999 or 2000., Main Outcome Measures: The Agency for Healthcare Research and Quality (AHRQ) has developed Patient Safety Indicators (PSIs) from hospital discharge data. To standardise these indicators across settings, AHRQ has provided software for risk-adjustment purposes so that the indicators can be compared across settings of care. We used the PSI software to calculate risk-adjusted PSI rates with 95% confidence intervals to compare veterans' inpatient care provided within and outside the VA system., Results: Risk-adjusted rates for nine of 15 PSIs did not differ between care provided within and outside the VA system. However, compared with care provided outside the VA system, risk-adjusted rates of decubitus ulcer, postoperative sepsis, infection due to medical care, postoperative respiratory failure and postoperative metabolic derangement occurred at lower rates within the VA system, while death in low mortality DRGs occurred at a higher rate in the VA system. Findings for patients aged 65 and older were similar to those of the entire age spectrum., Conclusions: Using AHRQ's PSI software, male veterans in New York who obtain their inpatient care within the VA received care that was comparable with or somewhat better than those who obtained their inpatient care outside the VA. The experiences of older patients reflected those of younger patients. Given that our findings are much more similar to reported comparisons between the VA and Medicare than to comparisons between the VA and the general population, we conclude that, should system comparisons be made, choice of comparison groups will be critical to accurate interpretation of findings; however, prior to such interpretation, the validity of the PSIs must be determined within VA.

Objectives: We quantified older (65 years and older) Veterans Health Administration (VHA) patients' use of the private sector to obtain 14 surgical procedures and assessed the potential impact of directing that care to high-performance hospitals., Methods: Using a merged VHA-Medicare inpatient database for 2000 and 2001, we determined where older VHA enrollees obtained 6 cardiovascular surgeries and 8 cancer resections and whether private-sector care was obtained in high- or low-performance hospitals (based on historical performance and determined 2 years in advance of the service year). We then modeled the mortality and travel burden effect of directing private-sector care to high-performance hospitals., Results: Older veterans obtained most of their procedures in the private sector, but that care was equally distributed across high- and low-performance hospitals. Directing private-sector care to high-performance hospitals could have led to the avoidance of 376 to 584 deaths, most through improved cardiovascular care outcomes. Using historical mortality to define performance would produce better outcomes with lower travel time., Conclusions: Policy that directs older VHA enrollees' private-sector care to high-performance hospitals promises to reduce mortality for VHA's service population and warrants further exploration.

Background: The Veterans Health Administration's (VHA's) National Center for Patient Safety developed a cognitive aid to help anesthesiologists manage rare, high-mortality adverse events., Methods: Six months after the aids were sent to VHA facilities with anesthesia machines, anesthesia providers were surveyed about their knowledge and use of the aid., Results: Seven percent of respondents had used the cognitive aid in an emergency ("emergent users"). Most (87%) of respondents were aware of the aid. Half used it only as a reference ("reference users"), 30% were nonusers, and 13% of respondents were unaware of the aid. User groups did not differ regarding exposure to emergencies. All emergent users reported that it helped during an emergency, and 93% reported that it was well designed and easy to use. Emergent users were more likely than other groups to have first found out about it through formal orientation (53%; p < .001). Nonusers (46%) and reference users (38%) were more likely than emergent users (30%) and those who never saw it (5%) to have first found out about it through informal communication with a colleague (p = < 0.001). The majority of those who never saw the aid first became aware of it through this survey (71%; p < .001). The aid was used most commonly for difficult airway., Discussion: A cognitive aid for use in rare emergencies proved clinically useful to anesthesia providers.

Background: Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS)., Methods: The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned., Results: Examples of projects in these facilities include intensive care unit (ICU) teams' patient-centered multidisciplinary rounds, surgical teams' preoperative briefings and debriefings, an entire operating room (OR) unit's adoption of "Rules of Conduct" for expected staff behavior, and an ICU team's use of the model for daily administrative briefings., Discussion: An MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.

The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report "To Err Is Human: Building a Safer Health System." However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence "shame and blame") to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.