VA Patient Safety:

Initiatives Promising but Continued Progress Requires Culture Change

T-HEHS-00-167: Published: Jul 27, 2000. Publicly Released: Jul 27, 2000.

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Pursuant to a congressional request, GAO discussed the Department of Veterans Affairs' (VA) effort to reduce and prevent patient adverse events in VA health care facilities through its new patient safety initiative.

GAO noted that: (1) VA has developed a number of initiatives that indicate it is moving toward a culture of safety in which systems are developed or revised to better detect and prevent adverse events; (2) some of VA's systems have been cited as potential models for other health care organizations; (3) for example, VA has established systems that incorporate the use of bar code technology to prevent blood product and medication administration errors; (4) VA introduced bar code technology in operating rooms to ensure that patients receive the correct blood product; (5) bar code technology is also being used when medications are administered to in patients to verify that the right patient is receiving the right drug in the right dose at the right time; (6) VA is completing its implementation of a revised mandatory adverse event reporting and prevention process, which will allow VA to identify systems and processes that require redesign; (7) this initiative is perhaps the most challenging because its success is dependent on VA establishing a culture in which employees feel safe to openly report actual adverse events as well as close calls; (8) in implementing its initiatives, VA used strategies that mirror some of those suggested by the Institute of Medicine (IOM) for creating a culture of safety; (9) however, GAO believes VA can benefit if it increases its emphasis on several leadership strategies cited by IOM; (10) in fact, VA agrees that it is appropriate to measure its progress against the IOM recommended strategies; (11) these include making patient safety a more prominent goal, establishing clear responsibilities and expectations, and communicating the importance of patient safety to all staff; (12) VA's interim draft strategic plan for fiscal years 2001 through 2006 better highlights patient safety as a goal than the current strategic plan, but does not yet include outcome measures for determining the effectiveness of its patient safety initiatives; (13) VA could also better ensure success if it prepared a detailed implementation plan that identifies how and when VA's various patient safety initiatives will be implemented, how they are aligned to support improved patient safety, and what contribution each initiative can be expected to make toward the goal of improved patient safety; and (14) VA could raise staff awareness and understanding of the importance of this effort by better communicating its commitment to establishing patient safety as a top priority.

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