Twenty years ago, when healthcare organizations investigated events that caused harm to patients, the focus was on individuals and their mistakes, rather than the integrity of the system within which people worked. Often called the “name and blame” culture, the emphasis in the wake of adverse events was not on learning and prevention, but rather individual correction via disciplinary measures.

In healthcare, like any other safety sensitive industry, we know that adverse events are more often the result of poorly designed systems that don’t interface well with humans creating the conditions for errors to occur. That’s why we’ve based VA’s patient safety program on a systems approach to analyzing error where the focus is on prevention, not punishment.

“Every day we focus on patient safety in VA,” according to Dr. Robin Hemphill, Director of VA’s National Center for Patient Safety (NCPS). “We especially recognize events held during Patient Safety Awareness Week (March 13-19), a week which brings focus to patient safety by the National Patient Safety Foundation.”

Training Sessions Mark Patient Safety Week

Next week, patient safety professionals across VA will sponsor events aimed at increasing awareness of patient safety at their facility.

To support programs that occur at local facilities, the VA National Center for Patient Safety is holding four training sessions. The VA has a systematic framework designed to improve patient safety. VA’s National Center for Patient Safety’s webinar training sessions next week will help builder stronger staff teams on these important foundational topics.

Tuesday will focus on how staff can use human factors to improve health care. Understanding how humans work, for both processes and equipment, can help reduce variation in health care.

NPCS will also sponsor a special session on a highly relevant change in healthcare designed to significantly improve patient safety via the elimination of tubing misconnections. Thomas Bauld, an NCPS bio medical engineer, will lead a presentation on the conversion to new tubing connectors for internal feeding.

The webinar will provide an update to recent developments and address the concerns about dosing accuracy of the current syringe for low-volume, high-potency medications.

Culture of Safety: Report Unsafe SituationsSmiling Nurse and patient

On Wednesday, the NCPS webinar will address culture, developing a fair and just culture as well as building a culture of safety. A fair and just culture is a necessary component of a Culture of Safety. Gary Sculli, Director of the NCPS Clinical Team Training program, tells us, “In a Culture of Safety, individuals are willing to self –report errors, but are also engaged in surveying the clinical environment and reporting unsafe conditions.  To this end, top leaders must actively take steps to create a Just and Fair culture.

“Leaders must openly encourage reporting, take the opportunity to reward those that do so, and be sure to provide feedback that steps were taken to change and improve unsafe conditions. Leaders must champion the Root Cause Analysis (RCA) process and openly support patient safety endeavors.”

Thursday’s webinar will educate staff on the RCA process. Participants will also work independently or in small groups to create a sample action plan they can share that during the webinar. These program are aimed at all VA employees and help staff understand more about how to make patient care in the hospital even safer.

Veterans are part of the patient safety program and to be truly effective, you need to be fully informed and actively involved in your care. Here are some important Patient Safety Tips for Veterans.

Beth J. KingAbout the Author: Beth J. King is the Program Manager for the VA National Center for Patient Safety


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Published on Mar. 10, 2016

Estimated reading time is 3.1 min.

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  1. John Nieporte March 22, 2016 at 3:05 am

    I’m a USMC Vietnam vet 100% disabled combat machine gunner with Purple Heart Medal. Diagnosed with severe PTSD; was shot in my spine by a sniper on a patrol. So im suffering with both mental and physical intense pain day and night. Im so angry that VA took away my primary pain managent opiod drugs and told me they wont fill them any longer!!!!!

    Does anyone else have ideas and suggestions for me; or is experiencing the same or a similar problem? Im married with children and not a drug abuser. PLEASE HELP ME TO GET SOME PAIN RELIEF HELP…I’ve been going to the same VA Hospital for nearly 45 years and the various doctors have tried to help so as a result they have tried ‘everything’ and nothing works but my pain meds they’ve now taken away…

  2. Victoria Christophe March 14, 2016 at 7:21 pm

    We need to help our Veterans more often.. they serve for our survival we need to return the favor

  3. Karen Schmitt March 11, 2016 at 3:03 pm

    Hello, My niece is a veteran of the U.S. Army. She is 45 and lives about an hour and a half from Madision WI. In January she was diagnosed with an 18cm ovarian cyst and I just found out her surgery isn’t scheduled until April 27, 2016. The cyst could rupture and cause irreparable consequences and even death. She had called several time to get her surgery updated to no avail. I am so concerned that the VA is not being proactive in her case. Is there anything she can do?
    Thank you for your replies.

    • js March 11, 2016 at 5:50 pm

      Hi Karen,
      Send your niece straight in to the patient advocate. If the patient advocate does not get it right, then direct contact with your congress person should key in some urgency on the matter. If this is a life and death issue it should be expedited. They should immediately authorize the use of the Choice Program if they cant get this taken care of pronto. It moves much faster after they elevate the urgency of the situation and it should not take any time to get some movement. Good luck.

    • DannyG March 18, 2016 at 9:35 pm

      Karen, pls let us know how it goes. Your family will be in my prayers! Hey,”js” – thanks for pitching in! That’s what family does!

  4. norman stewart March 11, 2016 at 11:31 am

    I was assaulted in the atlanta Vamc by a fellow veteran and it was swept under help no justice just me a victim victimized. told to drop my claim for malpractice to get 50% .

    • Paula sanford March 18, 2016 at 12:31 am

      I was assaulted while on duty as VA employee. Assaulted by a fellow employee. Yes swept under the carpet for sure. I am still pursing this issue.

  5. Hal Harrison March 11, 2016 at 10:21 am

    The VA mess just gets smellier and smellier the more it is stirred. It is time to put offenders against a wall. If a scheme works then it will be used over and over again to cheat and steal. If it not profitable to take the chance of getting caught, then and only then will this BS stop. Make people accountable, report it , measure it and if there is fraud, theft, and corruption, cut it out like a rotten appendix.

  6. Patrick jahnke March 10, 2016 at 2:02 pm

    Why do clinic refused to cc a veteran? Pain clinic? I still believe va heath care big brother watch over, I found out they said they look at my records said we can’t help, I seen 2 people were quacks!!!!!!! 1 help me with pain issues, she informed me I cc SE her no more because I can’t control my pain, nerves damage ankle, burn, pin and needle effect hit any time of day or night, from acdrug from va doctor, 2 she physical therapy specialists , she flip cards out tell me how to control pain, did not look at leg, just used flip cards , waste of my time drive 3 hrs.1 way. I’m still on guard with va care , it been passed to give out narcotics drugs but va still refuses give it out with new regs handed out. Wjhy does patient advocate takecweek call back ? Thier just a go between doc and the head office they don’t help out in my case . at least choice doctor helps me out for pain issues,

    • Norma March 18, 2016 at 11:14 am

      The only thing the VA can and is doing is screwing the veterans over. this comes from watch my husband have is pain medications taken away. Yes a few years ago the VA had him on such a high dose. I took it upon myself to slowly lowering his dose. He was doing good. My husband had surgery while recovering they took away him morphine which was only 15mg time released 2 times a day.Now they are not giving him his oxycodone 5mg 2 times a day. The timing has been against my husband. Now he is going through physical theropy without and pain meds.
      Last year my husband recieved forms from the pain clinic to fill out and send back right away. Nothing ever came of.

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