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 256 PATIENT SAFETY focused publications)
- 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.
- Keating JA, McKinley L, Safdar N. Coronavirus disease 2019 (COVID-19) and antibiotic stewardship: Using a systems engineering approach to maintain patient safety. Infection control and hospital epidemiology. 2020 Oct 12; 1-3.
- Grubenhoff JA, Ziniel SI, Cifra CL, Singhal G, McClead RE, Singh H. Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey. Pediatric quality & safety. 2020 Mar 1; 5(2):e259.
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(5 of more than 35 PATIENT SAFETY focused publication briefs)
- 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
- Excess Medication Supply Potentially High among Veterans Using VA Healthcare
This study sought to determine the prevalence of potential medication excess in the VA healthcare system – and to identify associated medication-, patient-, and system-level factors. Findings showed that medication excess was high among VA healthcare users in this study, with nearly two-thirds of patients (64%) experiencing at least one duplicative medication. Medication excess was more likely for...
Date: November 1, 2019
- Unintentional Consequences of FDA Warnings: Varenicline
This study examined the association between FDA drug safety communications and the use of varenicline (Chantix) – a prescription drug used to treat addiction to smoking. Investigators tracked varenicline and nicotine replacement therapy (NRT) prescribing and evaluated the potential consequences of decreased varenicline use on lost opportunities to assist patients with quitting smoking and health o...
Date: September 4, 2019
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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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The most recent "Patient Safety" seminars are displayed.
Leveraging VA Text Note Data for Quality Measurement: A Case Study of a Novel Measurement Tool for Cardiac Device Procedures
|| Branch-Elliman, Westyn
HSR&D Health System Impact Award: Enhancing Patient Safety by Preventing Catheter-Associated Urinary Tract Infection (CAUTI): The Journey Continues
|| Saint, Sanjay
The ED-PACT Tool: Communicating Veterans’ Care Needs After ED Visits
|| Cordasco, Kristina
De-implementing inhaled corticosteroids to improve quality and safety for patients with mild-to-moderate COPD: Mixed-methods findings of primary-care providers’ perspectives
|| Helfrich, Christian
Integrating Pattern Matching and Active Thinking Support in Information Displays for Clinicians
|| Weir, Charlene
Del Fiol, Guilherme
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