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Important Office that Most People Have Never Heard

Surgeons looking at x-rays of patient

Patient Safety is Job One

By Derek D. Atkinson, Public Affairs Officer VA National Center for Patient Safety
Tuesday, March 14, 2017

It’s VA’s National Center for Patient Safety (NCPS), and it has:

  • Contributed to an 82 percent decrease in deaths from suicide in VA inpatient mental health
  • Helped reduce major fall-related injuries by five per month since 2012
  • Fostered a strong culture of safety throughout the Veterans Health Administration
  • Created a five-step process for Ensuring Correct Surgery, including a timeout for safety before an invasive procedure or operation

“We work with some of the brightest and most passionate people who are completely dedicated to reducing and preventing harm to our Veterans,” said Dr. Robin Hemphill, VHA chief safety and risk awareness officer.

Patient safety is the prevention of inadvertent harm or injury to patients. It includes the identification and control of hazards and vulnerabilities that could cause harm to patients.

Valuable Tools Designed to Keep Veteran Patients Safe

NCPS measures and reports trends to leadership in an effort to create a strong culture of safety in VHA.  It created the Patient Safety Culture Survey, parts of which are also used by the Agency for Healthcare Research and Quality (AHRQ) as part of its patient safety survey.  This enables VHA facilities to compare their patient safety culture to those outside the VHA.

The Mental Health Environment of Care Checklist, created by NCPS in 2007 to evaluate and improve the safety of inpatient mental health units, has contributed to an 82 percent decrease in deaths from suicide in VA inpatient mental health units throughout the United States.

A Toolkit to Help Prevent Falls

Falls are regularly one of the highest categories of sentinel events reported to The Joint Commission. To address this patient safety issue, NCPS developed a Falls Toolkit. The Toolkit has contributed to five major fall-related injuries avoided per month since 2012.

“Passionate people completely dedicated to reducing and preventing harm to our Veterans.”

The Daily Plan® enhances patient safety by involving patients in their care. Veteran patients receive an itinerary, or road map that lets them see what will occur on a particular day. The plan encourages patients and family members to ask questions if something seems different than expected. This can help reduce potential errors and give Veterans and their caregivers’ peace of mind.

Communicating Clearly in Critical Situations

Clinical Team Training (CTT) was developed by NCPS to provide clinicians with the tools and strategies to practice effective teamwork behaviors and to communicate clearly, especially in critical situations.  CTT employs Crew Resource Management (CRM) principles, developed in the airline industry, to improve team leadership, assertive communication, situational awareness and clinical decision making.  Establishing a fair and just culture is critical for a thriving atmosphere of safety. My Voice Matters offers coaching, support and training for VA leaders on their journey to high-reliability through the establishment of a fair and just culture.

NCPS’ five-step process for Ensuring Correct Surgery has been presented to countless numbers of patients, VA staff and residents rotating through VA hospitals. This process includes 1) verification of proper informed consent, 2) standardized patient and procedure identification, 3) marking the procedure site, 4) reviewing relevant medical images, and 5) conducting a “timeout.” The “timeout” is a discrete pause for safety in the action prior to an invasive procedure or operation where the team confirms the above information.

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For Veterans Having Surgery

We have information that will help you to understand what will happen before your surgery and how your doctors and nurses will make sure that everything goes as planned.

If you are a Veteran or medical professional interested in a health care system that places a high priority on patient safety, look no further than your local VA Medical Center.