Patientsafety.va.gov

VHA National Center for Patient Safety Home

The NCPS was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. Our goal is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care. Patient safety managers at 151 VA hospitals and patient safety officers at 21 VA regional headquarters participate in the program.

Actived: 7 days ago

URL: https://www.patientsafety.va.gov/PATIENTSAFETY/

About the National Center for Patient Safety

(2 days ago) First Do No Harm. The Department of Veterans Affairs National Center for Patient Safety was established in 1999 to lead VA’s patient safety efforts and to develop and nurture a culture of safety throughout the Veterans Health Administration.. The primary goal of NCPS is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care.

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Patient Safety is Job One

(5 days ago) 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

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Patient Safety Huddle Board

(2 days ago) The Mental Health Residential Rehabilitation Treatment Program is the next area expected to implement the Patient Safety Huddle Board. Only time will tell what further benefts are realized from the patient safety huddle boards. Components of OVAMC’s Patient Safety Huddle Board.

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VA Care is High-Quality

(3 days ago) VA Care is High-Quality. A 2017 review of 69 published studies conducted by the independent RAND research organization concluded that the VA performed as well as, or better than, private health care systems on most quality care measures. 1 Additionally the RAND study reported that “In terms of effectiveness, VA facilities had similar or superior quality to non-VA facilities with respect to

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The New Generation Risk Tool for VA HFMEA

(1 days ago) VA has adapted the FMEA methodology to health care processes in order to reduce the frequency of unanticipated adverse events and ensure safer care for Veterans. 1 VA Healthcare Failure Mode and Effect Analysis (HFMEA) also helps VA facilities comply with The Joint Commission standards, which require accredited hospitals to select a high-risk

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Making a Difference: Patient Safety Fellows

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Mental Health Environment of Care Checklist

(8 days ago) Mental health and behavioral science service for psychiatric, alcohol, and drug dependency treatment areas require "Security Glazing" assemblies, resistant to breakage and use as weapons. 2. Security (seclusion) rooms, including room doors, use 11 mm (7/16 inch) laminated clear glass, clear heat strengthened glass clad polycarbonate, or clear

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Purchasing for Patient Safety

(8 days ago) A key component of the Veterans Health Administration’s (VHA) journey towards high reliability is the ability of NCPS and other VHA offices to recognize potential hazards before they enter the supply chain to ensure that the products used are safe, reliable and efficient.

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Health Care Human Factors Curriculum

(4 days ago) Health care facilities struggle to standardize approaches and decrease complexity. Incorporating human factors engineering principles in each facility’s service area can …

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Mental Health Environment of Care Checklist

(9 days ago) This article describes the development and implementation of the Mental Health Environment of Care Checklist (MHEOCC) designed to review the environment of care in mental health units and identify environmental hazards associated with increased suicide risk. We chose to institute the use of a checklist so that those approaches and techniques that we identified to possess value could be

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Patient Safety Centers of Inquiry (PSCI)

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Ensuring Correct Surgery

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Patient Safety: For the Media

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Resolving Missing or Absent Patient Issues

(8 days ago) Specifically designed for use by health care professionals, the process offers users analytical tools such as flow diagramming, decision trees and prioritized scoring systems. The topic was selected due to the facility location, the number of construction projects underway, the number of near miss events, and the medical center’s commitment

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VA Patient Safety Fellowships

(7 days ago) The VA National Center for Patient Safety, in cooperation with the VA Office of Academic Affiliations have teamed up to offer one-year fellowships in patient safety.. The fellowships provide in-depth education in patient safety practice and leadership. The program links individualized, mentored training at a number of training sites around the nation to a state-of-the-art curriculum in the

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Frequently Asked Questions

(7 days ago) One example is the Health Care Failure Mode and Effects Analysis (HFMEA) program. HFMEA is a five-step process that uses an interdisciplinary team approach to proactively evaluate a health care process. Designed by NCPS specifically for health care, the method uses analytical tools, such as flow diagramming, decision trees, and prioritized

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Going an Extra Mile for Patient Safety

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Patient Safety Improvement Corps

(7 days ago) Patient Safety Improvement Corps. Consistent with a positive assessment of NCPS by the Rand Corporation, the Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) selected NCPS to formulate, manage, and implement a multifaceted training program for state health officials and their hospital partners.

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Medication Safety

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The Daily Plain®

(1 days ago) The patient is the only component of the health care delivery system that is always present and yet the least likely one to be included as a resource. Patients and their families want to help ensure safety, however; there has been little professional attention on how best to actively involve patients or …

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Patient Safety Fellowships

(2 days ago) Health care administrators The fellowship year typically begins with a week-long intensive orientation to patient safety, including such topics as human factors engineering, root cause analysis, and health care failure mode and effect analysis.

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Focus on Falls Prevention

(4 days ago) Falls are a major concern at health care facilities nationwide, which is why Chanedra Mells, M.P.H., has focused her patient safety fellowship on fall prevention at the James A. Haley Veterans’ Hospital, Tampa, Fla. “After studying literature related to a Breakthrough Series on fall and injury prevention, I learned that fall prevention in hospice and palliative care was identified as an

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Biomedical Engineering

(3 days ago) Biomedical engineers often work side-by-side with clinical engineers – professionals who support and advance patient care by applying engineering and managerial skills to health care technology. NCPS uses biomedical, clinical, and systems engineering principles and techniques to support the safe use of medical devices at VA facilities.

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VA Boston Displays Transparency in Patient Safety

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Philips CPAP Recall

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VHA's HRO journey officially begins

(Just Now) VHA’s journey to become an HRO is consistent with National Patient Safety Goals (NPSGs) set forth by The Joint Commission, an independent, nonprofit organization that accredits and certifies approximately 21,000 health care organizations and programs in the U.S.

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Standardizing timeouts at the Phoenix VA

(6 days ago) The Phoenix VA Health Care System (PVAHCS) has a dedicated in¬patient and outpatient Chief Resident in Quality and Patient Safety (CRQS). The chief residents lead a local three-legged curriculum teaching concepts in quality improvement and patient safety to internal medicine residents at the University of Arizona College of Medicine, Banner University Medical Center and PVAHCS.

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Patient Safety Curriculum Workshop

(Just Now) Purpose: Develop faculty leadership at all VA facilities where medical residents train in order to pursue the objectives of the VA patient safety curriculum. More than half of the nation's residents train in VA health care facilities and are a crucial element in VA's effort to improve patient care, because they work on the front line, where there is more potential for change.

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Dedicated, Motivated, Safe and Sterile

(2 days ago) The Sterile Processing Service (SPS) at the Central Alabama Veterans Healthcare System (CAVHCS) is a dedicated team of professionals in the trenches of the patient safety improvement effort throughout the Veterans Health Administration (VHA).

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Milwaukee VA Medical Center’s Patient Safety Fair

(8 days ago) The Milwaukee VA Medical Center held a patient safety fair March 10 – 11, 2015 to celebrate National Patient Safety Awareness Week.. This year’s theme for the fair was baseball, with the tag-line, “Great Catch for Patient Safety.” Several individuals from a variety of departments partnered with us to develop the patient safety

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Revisiting the VA Boston Flu Fighters

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NCPS Staffer Receives Prestigious HFES Award

(8 days ago) The VA National Center for Patient Safety – headquartered in Ann Arbor, MI – was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. The primary goal of NCPS is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care.

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Taking a Shot at the Flu

(Just Now) The VA Boston Healthcare System’s Flu Taskforce implemented a strategic plan that has led to a significant increase in the system’s flu compliance rate, though VA employees are not currently mandated to get the flu vaccination. “When we started the effort last August, just over 6 percent of our staff members had received their flu shots,” said Chief of Occupational Health Robert

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A Creative Approach to Learning

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Psychologist aims to make mental health units safe

(5 days ago) Mental health units were required to go through their units every quarter using the checklist to ensure everything was as safe as possible. If there were areas that didn’t meet the checklist’s recommendations, that hospital would create an improvement plan with concrete action items on how the unit would meet those standards.

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VA hospitals outperform private hospitals

(6 days ago) According to an independent Dartmouth study recently published in the Annals of Internal Medicine, Department of Veterans Affairs (VA) hospitals outperform private hospitals in most health care markets throughout the country. “This is proof that the hard work and dedication of our VA employees is making a real difference in the lives of our nation’s Veterans,” said VA Secretary Robert

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Pittsburgh VA's Center for Medical Product Testing

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"Learning the Ropes" of Patient Safety

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Postoperative Outcomes in VA Improved

(2 days ago) A study of the post-operative outcomes in the Veterans Health Administration shows that rates of complications and mortality following complications, known as failure to rescue, improved significantly within the VA during the last 15 years.

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