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Commentary

The Role of Research in Addressing Key Issues and Challenges in Patient Safety

Since the first studies of patient safety in the early 1990s¹ and with the seminal work of the Institute of Medicine in 2000,² researchers have observed that much of the patient harm that occurs in healthcare is preventable. In September 2023, the President’s Council of Advisors on Science and Technology report, “A Transformational Effort on Patient Safety,”³ highlighted that progress in addressing rates of adverse health outcomes has been unacceptably slow; the report also recognized that while there is great potential for near-term research and innovation to boost patient safety, widespread implementation of today’s evidence-based solutions will significantly reduce harms.

Since its inception in 1999, the VA National Center for Patient Safety (NCPS) has focused on reducing or eliminating preventable patient harm in the Veterans Health Administration (VHA) by translating research findings to care delivery. By developing and implementing a systematic patient safety reporting system that identifies and addresses the root causes of adverse events and near misses (close calls),⁴ and a national safety program and patient safety workforce, NCPS has taken a human-factors approach to improving patient safety within VHA. 

Research in patient safety has contributed greatly to understanding how to improve systems of care to reduce preventable harm. Research in patient safety has shown us that improvements to systems of care include, but are not limited to, standardizing the methodology for medical procedures, and using specific bundles of interventions; and that, together, these efforts can reduce preventable harm. For example, specific protocols for reducing surgical site infections and hospital-acquired infections have improved care for patients. The NCPS has managed a program of translational research in patient safety called the Patient Safety Center of Inquiry (PSCI). The PSCI program funds small research groups (PSCIs) to evaluate and translate patient safety research findings into standard evidenced-based practices that improve patient safety across the entire VHA system.

First funded in 1999, PSCIs promote the study of patient safety areas of interest; over the years, these groups have made valuable contributions to the improvement of patient safety within VHA and beyond. Using the knowledge developed by the PSCI program, NCPS has assisted with the distribution of tools and products designed to promote patient safety, including clinical tools, cognitive aids, educational materials and toolkits, measurement tools, policy reports, handbooks, and directives. Early PSCI program contributions included the first use of simulation to improve patient care in VHA, development of the Moderate Sedation Tool Kit, improvement in the safety of drug prescribing practices and medication administration, improvement in home safety for high-risk patients, improvement in the sterilization of reusable medical equipment, application of usability testing and human factors design to Bar-Code Medication Administration, studies of fatigue and its effects on clinicians’ performance, and improvements to patient safety in the use of the electronic medical record.

Over the twenty-year period, PSCIs have contributed to improvements in multiple areas including suicide prevention and treatment, patient safety measurement, simulation training, fall and fall-related injury prevention, drug prescribing and administration practices, and reduction of hospital-acquired infections. A summary of PSCI accomplishments includes the following.

Suicide prevention. Improved the process of safety planning for suicidal patients. Identified strategies shown to have the greatest effect in preventing completed suicide. Developed an intervention to reduce Veteran suicide after discharge from mental health units; and developed interventions in the community so that Veterans who are currently not getting care in VHA can either access VA suicide prevention interventions or receive mental healthcare in VHA.

Reduce delays in care for cancer patients. Developed a toolkit to improve timely communication of test results and guidance to reduce “missed” test results as well as delays in diagnosis and treatment. Created a portfolio of triggers for multiple test results, which can be applied to all VA facilities as well as a prototype software system called AWARE (Alert Watch and Response Engine) to support providers by presenting reminders and recommendations if a specified type of abnormal alert notification has not been addressed.

Opioid abuse prevention. Developed and piloted tools to promote safe opioid therapy prescribing in primary care, including point-of-care decision support and an opioid dashboard. 

Falls prevention. Updated the NCPS Falls Toolkit and developed protocols for reducing fall injuries, hazardous wandering, and improved patient handling. Evaluated the properties of commercially available medical helmets; conducted an analysis of wheelchair falls, and integrated falls data into a data display tool. Led multiple national collaboratives in VA and Veterans Homes to reduce injuries due to falls.

Reduce hospital-acquired infections. Development and piloting of a program to reduce rates of catheter-associated urinary tract infections (CAUTI). Created a comprehensive list of appropriate indications for the initial placement and continued use of indwelling urinary catheters, using the best available scientific evidence and a systematic rating process of appropriateness by a multidisciplinary expert panel, as well as elucidating effective strategies for implementing an evidence-based CAUTI prevention program within VA and in long-term care. In addition, developed and implemented protocols for the safe use of peripherally inserted central catheter (PICC) lines to decrease hospital-acquired infections and a human factors-based system to study and reduce hospital-acquired infections.

Delirium treatment. Development and piloting of a delirium toolbox to better identify and treat delirium in VHA. Built an electronic delirium risk measure using the VA Corporate Data Warehouse. The PSCI conducted a national breakthrough series to disseminate the delirium toolkit.

Patient safety measurement. Developed and evaluated a pilot patient safety dashboard. The current version of the data display tool includes overall event rates and rates within categories.

Renal safety. Implemented a novel and full service Renal Interdisciplinary Safety clinic (RISC Safety-PACT) designed to reduce medical errors in Veterans with kidney disease that account for unexpected hospitalizations and ER visits.

Medical product safety review. Identified and advised the purchase of safer medical products across VHA, identified, and mitigated safety issues with medical products in use at VHA, and informed the safe design of medical products.

Medication deprescribing. Developed a standardized toolkit to reduce the number of medications prescribed to older Veterans and disseminated the tools in a breakthrough series.

Community care safety. Established tools to reduce medication errors in Veterans who received care in both VHA and the community as well as toolkits to help older Veterans transition back to the community after surgery and prepare for elective surgeries using pre-habilitation.

Widespread implementation of evidence-based solutions is an integral step in NCPS’s goal to move VHA towards zero preventable harms. Moreover, VHA’s commitment to becoming a high reliability organization promotes principles of a safe and just culture and encourages voluntary reporting of close calls and adverse events. There is still much work to be done, including funding patient safety research with known gaps in care, including disparities and diagnostic errors, and supporting nationwide efforts to improve interoperability of data and artificial intelligence for improved detection of patient safety events, as we continue to strive to deliver excellent care with zero preventable harms.

References

1. Leape L, Brennan TA, Laird N, et al. “The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II,” New England Journal of Medicine 1991;324(6):377-84.
2. Kohn LT, Corrigan JM, Molla SD, editors. To Err is Human: Building a Safer Health System. Institute of Medicine Committee on Quality of Health Care in America. Washington (DC)       National Academies Press (US) 2000.
3. Executive Office of the President, President’s Council of Advisors on Science and Technology, “Report to the President, Transformational Effort on Patient Safety,” September 2023.
4. Bagian JP, Lee C, Gosbee J, et al. “Developing and Deploying a Patient Safety Program in a Large Health Care Delivery System: You Can’t Fix What You Don’t Know About,” The Joint Commission Journal, October 2001;27(10):522-32.