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Veterans Health Administration


Working to Achieve Safe Care for Veterans

A nurse talks with a senior man about medications

Patient Safety is a job we do with one person in mind — the Veteran.

by Hans Petersen, VA Staff Writer
Tuesday, March 4, 2014

Seven Days of Recognition — 365 Days of Commitment to Safe Care

March 2-8 is Patient Safety Awareness Week — an opportunity to learn about the wide range of actions VA has taken to improve patient safety.

To learn more about VA’s patient safety priority, visit the National Center for Patient Safety website.

The VA National Center for Patient Safety was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration.

There are patient safety managers at 151 VA hospitals and patient safety officers at 21 VA regional headquarters.

VA’s goal: the reduction and prevention of inadvertent harm to our patients. Reducing or eliminating harm to patients is the real key to patient safety.

VA’s patient safety program is based on a systems approach to problem solving — focused on prevention, not punishment.

The idea is not to target people or participate in the “name and blame” culture of the past.

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.

VA is not 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.

 While we focus on patient safety as an everyday responsibility, Patient Safety Awareness Week allows us time to highlight some of the exciting ways people all over the VA are working to achieve high quality and safe care for their patients. 
— Robin R. Hemphill, Chief Safety and Risk Awareness Officer, Director National Center for Patient Safety

A Culture of Safety

VA’s approach creates a level of trust that helps perpetuate a culture of safety.

VA uses a multi-disciplinary team approach, known as root cause analysis (RCA) to study health care-related adverse events and close calls. RCA teams investigate how well patient care systems function, focusing on “how” and “why,” not “who.”

According to Dr. Hemphill, “Root cause analysis is a tool for identifying system failures and vulnerabilities and then developing prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.”

Dr. Hemphill concludes, “We believe people come to work to do a good job, not to do a bad job. Given the right set of circumstances, any of us can make a mistake. We must force ourselves to look past the easy answer, that an adverse event was someone’s fault. We want to look at the tougher question, why did this adverse event occur?

“That’s our job at the National Center for Patient Safety, a job we do every day with one person in mind…the Veteran.”