It’s VA’s National Center for Patient Safety (NCPS), and it has:

  • Contributed to an 82 percent decrease in deaths from suicide in VA inpatient mental health
  • Helped reduce major fall-related injuries by five per month since 2012
  • Fostered a strong culture of safety throughout the Veterans Health Administration
  • Created a five-step process for Ensuring Correct Surgery, including a timeout for safety before an invasive procedure or operation

“We work with some of the brightest and most passionate people who are completely dedicated to reducing and preventing harm to our Veterans,” said Dr. Robin Hemphill, VHA chief safety and risk awareness officer.

Patient safety is the prevention of inadvertent harm or injury to patients. It includes the identification and control of hazards and vulnerabilities that could cause harm to patients.

Valuable Tools Designed to Keep Veteran Patients Safe

NCPS measures and reports trends to leadership in an effort to create a strong culture of safety in VHA.  It created the Patient Safety Culture Survey, parts of which are also used by the Agency for Healthcare Research and Quality (AHRQ) as part of its patient safety survey.  This enables VHA facilities to compare their patient safety culture to those outside the VHA.

The Mental Health Environment of Care Checklist, created by NCPS in 2007 to evaluate and improve the safety of inpatient mental health units, has contributed to an 82 percent decrease in deaths from suicide in VA inpatient mental health units throughout the United States.

Man fallen down on the stairs

A Toolkit to Help Prevent Falls

Falls are regularly one of the highest categories of sentinel events reported to The Joint Commission. To address this patient safety issue, NCPS developed a Falls Toolkit. The Toolkit has contributed to five major fall-related injuries avoided per month since 2012.

“Passionate people completely dedicated to reducing and preventing harm to our Veterans.”

The Daily Plan® enhances patient safety by involving patients in their care. Veteran patients receive an itinerary, or road map that lets them see what will occur on a particular day. The plan encourages patients and family members to ask questions if something seems different than expected. This can help reduce potential errors and give Veterans and their caregivers’ peace of mind.

Communicating Clearly in Critical Situations

Clinical Team Training (CTT) was developed by NCPS to provide clinicians with the tools and strategies to practice effective teamwork behaviors and to communicate clearly, especially in critical situations.  CTT employs Crew Resource Management (CRM) principles, developed in the airline industry, to improve team leadership, assertive communication, situational awareness and clinical decision making.  Establishing a fair and just culture is critical for a thriving atmosphere of safety. My Voice Matters offers coaching, support and training for VA leaders on their journey to high-reliability through the establishment of a fair and just culture.

NCPS’ five-step process for Ensuring Correct Surgery has been presented to countless numbers of patients, VA staff and residents rotating through VA hospitals. This process includes 1) verification of proper informed consent, 2) standardized patient and procedure identification, 3) marking the procedure site, 4) reviewing relevant medical images, and 5) conducting a “timeout.” The “timeout” is a discrete pause for safety in the action prior to an invasive procedure or operation where the team confirms the above information.

PSAW Banner

For Veterans Having Surgery

We have information that will help you to understand what will happen before your surgery and how your doctors and nurses will make sure that everything goes as planned.

If you are a Veteran or medical professional interested in a health care system that places a high priority on patient safety, look no further than your local VA Medical Center.

About the author: Derek D. Atkinson is a Public Affairs Officer with the VA National Center for Patient Safety 

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Published on Mar. 14, 2017

Estimated reading time is 3.2 min.

Views to date: 88


  1. james schnitzler March 30, 2017 at 10:52 am

    i have had nothing but good care at the cincinnati V.A. and the out patient clinic i guess it is all according to what part of the country you live in.

  2. Ronald R. Baker March 18, 2017 at 11:32 am

    I think it great that the VA is doing in the aging area

  3. James Thomas Coursey March 17, 2017 at 3:41 pm

    Is there help for me,, I had cocusion and treated at Lakehurst New Jersey naval medical unit. I fell several times a year and six years ago had serious fall causing traumatic brain injury. Medical record misplaced or lost by unit in 1963. Va told me I was sol, I saying it nicer than va officer did. Please help, thanks

  4. robert a melita March 17, 2017 at 2:27 pm

    I recently had a total right shoulder arthropaty at the Audie Murphy V.A. Hospital in San Antonio, Texas. Just want to say that my pre, and post up surgery was very informative and detailed, And all the Doctors and nursing staff was outstanding!!!! A big thumbs up.

  5. Hutch Dubosque March 17, 2017 at 2:21 pm

    Why is there no “Mold Remediation” program ongoing at the VA Medical Center in Northport, NY. This Facility has seventeen (17) actively in-use buildings that were built in 1927 and are riddled with black mold. Both Patients and Employees are experiencing above normal respiratory distress symptoms. The Hospital management is in total denial of this situation. This problem must be addressed before the more susceptible Patient and Employee population becomes irrevocably damaged.

  6. Donald carton March 17, 2017 at 1:23 pm

    I need a job that will help me stay independent ! Can you provide???

  7. Larry Nelson March 17, 2017 at 12:22 pm

    I have had cancer three times prostate cancer bladder cancer and urithreal cancer, I have been gone through two operations to remove the items listed above, on the bladder cancer the Dr’s did not tell me the truth about the operation, I later found out that one of the Dr’s had been involved in devolveping the procedure and that I was used to teach the other Dr’s. , on the second operation there was so much scar tissue that I was in surgery for seven to ten hours, after the surgery I devolved pneumonia and spent a week on a resporitr and all most lost my life. The VA Dr’s never even came and tell me that they were sorry for all that happened, it would have been nice, but I never most of the Dr’s again. I have been lied to so many times by Dr’s that I don’t trust any of VAs Dr’s. I have had other times that Dr’s have lied to me. But that’s another story.

  8. Thomas L. Wheelus March 17, 2017 at 11:48 am

    What the VA need is an oversight board. When something goes wrong the poor veteran gets caught up in the same loop that failed in the first place. The NOD procedure is a farce. The appeal process is a failure. There is no assistance without hiring a lawyer to address the problems. .

Comments are closed.

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