VA Leads Nation In Patient Safety

Washington, D.C. – The Department of Veterans Affairs (VA) is leading the nation in eliminating problems that result in medical errors, according to the chief physician at the veterans agency.

“VA’s emphasis upon patient safety and ensuring consistently reliable, high-quality care has already resulted in improvements that meet or exceed national standards,” said Acting Under Secretary for Health Dr. Thomas L. Garthwaite.

VA has created four Patient Safety Centers of Inquiry to develop innovative solutions to critical challenges in patient safety.

Dr. Jim Bagian, a former astronaut and director of VA’s National Center for Patient Safety, said, “There are many examples of how VA now sets the standard for error prevention and quality improvement through application of new technologies and process redesign.”

Among the examples cited by Bagian are:

• VA recently revised its Patient Safety Handbook and training for health-care workers in patient safety. A recent report by the Institute of Medicine endorsed VA’s approach in understanding the processes that are prone to error and finding solutions that can be widely applied.  
• More than four years ago, VA began using a “bar-code” system for medication, similar to the computerized codes in stores. This cut medical errors by two-thirds. VA officials plan to have bar-coding in all VA medical centers next year, making the veterans agency the first health-care system to use bar-codes nationwide.  
• Computerized patient records remind health-care workers of routine services such as immunizations and cancer screening.  
• VA facilities use electronic entry of prescriptions to eliminate mistakes from illegible handwriting.  
• In 1991, VA created the National Surgical Quality Improvement Program to give systematic insight into surgical care and to improve surgical outcomes. During the last five years, this program led to a 10-percent reduction in mortality and a 30-percent reduction in post-operative complications.  
• In 1995, a performance measurement system began to provide high quality care across VA. It monitors adherence to clinical practice guidelines and measures clinical outcomes.  
• This year, VA is requiring health-care workers to attend 40 hours of instruction on quality improvement as part of their continuing education.  
• VA recognizes innovative solutions to patient safety issues through its Patient Safety Awards Program.  
• To benefit both VA and the nation, in 1997 Garthwaite’s predecessor, Dr. Kenneth W. Kizer, convened the National Patient Safety Partnership. A public-private partnership, it brings together the best insights from some of the nation’s leading health-care organizations and scholars on health care safety.