The role of patient safety research is to understand how best to ensure that patients, their clinical environments, and their clinical processes and systems are safe—and not vulnerable to causing inadvertent harm. VA health services investigators conduct research into patient safety that encompasses everything from appropriate patient identification processes to preventing hospital-acquired infections to assessing clinical and organizational leadership attitudes.
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(5 of more than 257 PATIENT SAFETY focused publications)
- Datta R, Barrett A, Burk M, Salone C, Au A, Cunningham F, Fisher A, Dembry LM, Akgün KM. Surveillance of adverse drug events associated with tocilizumab in hospitalized veterans with coronavirus disease 2019 (COVID-19) to inform patient safety and pandemic preparedness. Infection control and hospital epidemiology. 2021 May 14; 1-4.
- Mull HJ, Rosen AK, Charns MP, Itani KMF, Rivard PE. Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions. Journal of Patient Safety. 2021 Apr 1; 17(3):e177-e185.
- Singh H, Carayon P. A Roadmap to Advance Patient Safety in Ambulatory Care. JAMA. 2020 Dec 22; 324(24):2481-2482.
- Ziemba JB, Tessier CD, Harris AM. Patient safety education and perceptions of safety culture in American and Canadian urological residency training programs. The Canadian Journal of Urology. 2020 Dec 1; 27(6):10431-10436.
- Hannawa AF, Spitzberg BH, Childress MD, Frankel RM, Pham JC, Wu AW. Communication science lessons for patient safety and quality care. Journal of Patient Safety and Risk Management. 2020 Oct 27; 25(5):doi.org/10.1177/2516043520926424.
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(5 of more than 37 PATIENT SAFETY focused publication briefs)
- Need for Systemic, Multi-Level Interventions for Patient-Perpetrated Sexual Harassment in VA Healthcare Settings
This study sought to identify challenges and stakeholder recommendations for addressing patient-perpetrated sexual harassment of women staff and patients at VA facilities. Findings highlight the complexity of addressing patient-perpetrated harassment and underscore the need for systemic, multi-level interventions. Perceived organizational-level challenges included a climate of tolerance for harass...
Date: February 25, 2021
- Veterans Open to Discussing Firearms Storage Safety in Primary Care Setting
This quality improvement project – part of a larger study to develop a training program on firearms storage safety (FSS) for VA primary care teams – describes Veterans’ perspectives on discussing FSS during primary care visits. Most Veterans in the study agreed that primary care is an acceptable setting for FSS discussions, but staff need to build rapport and trust by using a personal, caring, and...
Date: January 26, 2021
- JAMA Features Reflections on “Crossing the Quality Chasm” 20 Years Later
This issue of JAMA includes two articles that reflect on the recommendations of the Institute of Medicine’s 2001 Crossing the Quality Chasm report that, 20 years ago, asked healthcare stakeholders to collaborate in order to provide care that is safe, effective, patient-centered, timely, efficient, and equitable. Both articles discuss how to make more progress toward these goals, while a third arti...
Date: December 22, 2020
- VA HIT-Related Outpatient Diagnostic Delays
This study evaluated the role of health information technology (HIT) in the root cause analyses (RCAs) of outpatient diagnostic delays submitted to the VA National Center for Patient Safety, which leads patient safety initiatives and uses RCAs of adverse events and close calls to promote learning across the VA healthcare system. Findings showed that of the 214 RCAs included in this study, 88 invol...
Date: June 25, 2020
- Eight Organizational Target Areas for Improving Access to Primary Care
This study sought to identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel. Findings showed that optimal access to primary care for enrolled patient populations requires active ongoing management of at least eight diverse target areas (two organizational structure targets, four process improvements, an...
Date: February 1, 2020
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( 5 of more than 27 PATIENT SAFETY focused projects
|| Promoting Antimicrobial Stewardship and Patient Safety by Implementing Interventions to Evaluate and Delabel Penicillin Allergy
|| Off-Label Use of Antipsychotics: Determinants and Impact on Patient Safety
|| How to Interpret and Use Patient Safety Indicator (PSI) Reports
|| Improving Patient Safety: Context and Nurses' Work Processes for Pressure Ulcers
|| Circumventing Health IT: Identifying Patient Safety Risks
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