Health Services Research & Development

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VA Research into Patient Safety

March 2018


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Patient Safety Awareness Week is March 11-17. Patient safety is a far-reaching concern, and can include everything from providers’ physical approach to moving a patient to hand-washing and disinfection protocols. Within VA, patient safety also focuses on the reduction and prevention of inadvertent harm to Veterans as a result of their using VA healthcare—and evidence that supports effective patient safety interventions is an important component of ensuring Veterans’ health. Investigators in VA’s Health Services Research & Development Service (HSR&D) conduct a wide variety of research in the area of patient safety, and the following highlights look at just a few of those ongoing and completed studies.

Investigator Insights Video Series: Patient Safety

  • Improving Medication Safety for Veterans. In this video, Mark Bounthavong, PharmD, MPH, with VA’s Pharmacy Benefits Management (PBM) Academic Detailing Service (ADS), talks about his research to improve medication safety in VA. Dr. Bounthavong discusses academic detailing—a method of providing healthcare professionals with balanced, evidence-based pharmaceutical information through direct one-on-one social marketing techniques.

HSR&D Publication Briefs: Patient Safety

  • VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans. Over the past two decades, a dramatic rise in the sale of prescription opioids in the United States has coincided with the rise of opioid overdose deaths and other opioid-related adverse outcomes. Further, prescribing higher total daily dosages of opioids and co-prescribing benzodiazepines have been associated with a greater likelihood of opioid overdose. In response, VA leadership developed and implemented the Opioid Safety Initiative (OSI) in 2013 to promote safer opioid-related prescribing in the VA healthcare system. In this study, investigators examined changes associated with OSI implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Learn more

  • Identifying Risks and Opportunities in Outpatient Surgical Patient Safety. Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. In this study, investigators interviewed VA surgical staff to gain insight into factors associated with AEs in outpatient surgery. Learn more

  • Systematic Review of Patient Safety Measures in Adult Primary Care. Annual outpatient visits in the U.S. far outnumber inpatient admissions, yet the development of patient safety measures has focused on inpatient care. In this systematic evidence review, authors sought to identify published articles detailing safety measures applicable to adult primary care. A total of 21 articles were identified, providing specifications for 182 safety measures. Each measure was classified into one of six outpatient safety dimensions: medication management, sentinel events, care coordination, procedures and treatment, laboratory testing and monitoring, and facility structures/resources. The review indicated that when compared to the multitude of available inpatient safety measures, the number of existing adult primary care measures is low. Learn more