Patient safety the VA way: One hospital can point the way for others to follow

Its focus is prevention, not punishment

The efforts by the U.S. Department of Veterans Affairs (VA) to improve patient safety are paying huge dividends for the hundreds of hospitals participating in its system of adverse-event reporting and analysis, suggesting that other health care providers could benefit from adopting the same techniques.

As all health care providers focus more on patient safety, the VA’s National Center for Patient Safety (NCPS) is being hailed as a proven way to make health care safer. The NCPS recently received the John E. Eisenberg Award in Patient Safety for System Innovation, awarded by the Joint Commission on the Accreditation of Healthcare Organizations and the National Forum for Healthcare Quality and Reporting. The VA’s patient safety program relies on a method that combines voluntary and mandatory reporting systems, root-cause analysis, and corrective actions to improve patient safety. The NCPS represents a unified and cohesive patient safety program, with active participation by all 172 VA hospitals supported by dedicated patient safety managers, says Caryl Lee, RN, MSN, the NCPS program manager in Ann Arbor, MI. Lee says the program is unique in health care because it focuses on prevention rather than punishment, applying human factor analysis and the safety research of "high-reliability organizations" such as aviation and nuclear power to identify and eliminate system vulnerabilities.

The program began in 1999 and relies on a multidisciplinary staff of nurses, biomedical engineers, safety engineers, pharmacists, attorneys, and others. The goal of the NCPS is to improve patient safety throughout the VA medical system, so the staff concentrate on collecting information about adverse events or close calls. Those events are carefully analyzed to determine how they might be avoided in the future, and the results are applied throughout the VA medical system.

"One benefit is that all of the VA hospitals can learn from a single experience instead of waiting for it to happen to them. We’re learning from one hospital’s experience so that we can improve care at 171 other facilities," Lee says. "The same idea can be applied to other health care organizations just as well. If you have five hospitals, a system like we have with the NCPS can help all five learn from each other. If you have five departments, a smaller system can help you bring all of your experience together."

Two reporting systems make up the backbone of the NCPS. One is internal, essentially a root-cause analysis system with VA software designed to support it. Hospitals are encouraged to conduct team-based analyses of adverse events or close calls. The findings of the root-cause analyses are forwarded to the NCPS headquarters, where Lee and the rest of the patient safety experts can watch for system-level vulnerabilities. A patient safety risk at one VA hospital could represent a risk present in all the VA hospitals, so the NCPS team can act to eliminate that risk across the board.

The second reporting system is called the Patient Safety Reporting System (PSRS) and is patterned after the aviation industry’s safety reporting system. In that industry, anyone working with aircraft is encouraged to report observations about accidents or close calls so that the Federal Aviation Administration or the National Transportation Safety Board can spot systemwide problems. In the VA system, all employees are encouraged to report their patient safety concerns to the PSRS database, which is managed by the National Aeronautics and Space Administration (NASA). Employees are encouraged to report in narrative form explaining what happened, why they think it happened, and what solution might keep it from happening again. The analysts at NASA act as impartial middlemen, stripping the patient safety reports of any identifying information before determining what lessons might be gleaned from them. NASA then reports to the NCPS about lessons that might be applied throughout the VA system.

"The anonymity is a big factor in getting good information through the PSRS," Lee says. "We think of this system as sort of a safety valve to get people to report their concerns. Reporting has increased astronomically, particularly with close calls, which is something people didn’t used to talk about."

NCPS also provides training and news updates to the VA hospitals, sending alerts that notify providers of recurrent problems with a particular medical device, for instance. Much of the training focuses on human engineering, trying to design systems so that they take the burden of memory and vigilance off of the individual provider and allow it to focus on decision making. In addition, the NCPS offers specific tools such as its "Triage Cards," a set of small laminated cards that one can use to prompt questions after an adverse event or close call. In the "Human Factors — Fatigue/ Scheduling" section, the questions include these: Were the levels of vibration, noise, or other environmental conditions appropriate? Did scheduling allow personnel to have adequate sleep? Was the environment free of distractions? 

Many of the tools used by the NCPS can be found on the group’s web site at

"We have had lots of non-VA folks take our training. Health care providers are more than welcome to look at our tools and techniques, much of which is available on our web site," Lee says. "Many things like the health care modes effects analysis are completely transferable to your own organization. Just like we’ve borrowed from other fields like aviation, we’re totally happy if people look at our work and adapt it for themselves."

That offer is echoed by James Bagian, MD, PE, director of the National Center for Patient Safety. Bagian works extensively with non-VA health care providers interested in adopting the NCPS systems, and he says the private sector can adopt the tools with little difficulty. Health care providers in Australia, Sweden, Denmark, and Japan have adopted the NCPS systems with success, he says.

"The NCPS puts a lot of good patient safety ideas into a framework," he says. "Rather than just the theoretical, saying it would be nice if we could do this, it leads you through a system that helps you put those ideas into action. You can have lots of bells and whistles, but if you don’t show people how to actually use something like the root-cause analysis to get useful information, you’re just wasting everyone’s time."

A major component of the NCPS philosophy is the focus on close calls, Bagian says. It used to be that no one ever reported or analyzed close calls, and only in the past few years has that changed somewhat. But even now, he says, providers do not study close calls thoroughly enough.

"When I ask if you do a root-cause analysis for a close call just the same as if you had killed someone, almost nobody says yes," Bagian says. "If you’re just reporting that close call and not acting on it, you’re not doing any good. You have to go after it and study it carefully if you want to learn anything from it."