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Health Services Research & Development

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Spotlight on Patient Safety

March 2021


In 1999, the Institutes of Medicine (IOM) released the landmark report, To Err Is Human: Building a Safer Health System, which indicated that each year as many as 98,000 people die in hospitals as a result of preventable medical errors. This IOM report stressed the importance of patient safety, which, as defined by World Health Organization’s World Alliance for Patient Safety, is “the absence of preventable harm to a patient during the process of healthcare, and reduction of the risk for unnecessary harm associated with healthcare to an acceptable minimum.”

Ensuring patient safety can take on many forms—some are simple, such as double-checking a birth date or a patient’s name; while others may be more complex, such as appropriate nurse staffing ratios or background administrative processes. To promote best practices for safe and optimal patient care throughout VA, the VA National Center for Patient Safety (NCPS) guides policies and strategies in order to:

  • Measure and mitigate harm to Veterans and those who support their care;
  • Track utilization and address deficient patient admission and discharge practices;
  • Model characteristics of a High Reliability Organization including promotion of clinical team training, and a just and safe culture; and
  • Evaluation of healthcare solutions, technology, and innovations from a patient safety and value-based perspective.

Researchers with VA’s Health Services Research and Development (VA HSR&D) service conduct an array of investigations that help VA continue to ensure safe care for all Veterans. These studies range from how to prevent in-hospital falls to developing better methods of assessing pre-surgical risk factors. The following studies represent just a few of HSR&D’s completed and ongoing investigations into various aspects of patient safety.

“Prehabilitation” Services Improve the Perioperative Care of Frail Veterans Following Major Abdominal Surgery

Prehabilitation  Services Improve the Perioperative Care of Frail Veterans Following Major Abdominal Surgery


For older Veterans who are considered “frail”—a clinical syndrome marked by muscle atrophy, diminished strength, decreased physical activity, and exhaustion—of major surgical procedures can result in significant mortality, morbidity, or institutionalization. Frailty is independent of any specific disease, but it increases with age, and is a more powerful predictor of increased post-operative problems than predictions based on age or comorbidity alone. As both the US and Veteran populations grow older and more frail, it is important to identify effective strategies for improving the perioperative care and outcomes for frail patients. In a major pilot study, funded by VA HSR&D and VA’s Rehabilitation Research & Development services, investigator Daniel Hall, MD, showed that "prehabilitation” exercise therapy had the potential to improve surgical outcomes among frail Veterans. Prehabilitation aims to augment patients' capacity to compensate for the stress of both surgery and recovery, and unlike rehabilitation, takes place prior to surgery. In as little as 3 weeks between diagnosis and surgical treatment, Dr. Hall demonstrated clinically meaningful improvements in grip strength and 6-minute walk test that may translate into improved postoperative outcomes. The prehabilitation period also permits goal clarification to ensure that the treatment rendered is consistent with the patient’s values and goals, especially in light of frailty-associated risks, and this effort increased patients’ self-reported perception of the patient centeredness of their care plans.

In 2019, Dr. Hall entered his Preoperative Frailty Screening and Prehabilitation program into the VHA Shark Tank Competition where it competed among hundreds of other submissions. After being identified as a winner at the VHA Shark Tank Competition, the practice went through replication at the Iowa City VA over the course of FY20. At the end of FY20, Dr. Hall developed a robust implementation guide to help other facilities navigate the implementation at their respective sites, including the five VAMCs in VISN4 who will be implementing frailty screening as part of the recently funded QUERI Program, Safer Aging through Geriatrics-informed Evidence-based practices.

Dr. Hall is now a National Diffusion Fellow and is supported by the Diffusion of Excellence Program as he works to diffuse his practice to all of VHA over the course of the next three years. For those with a VA email address, more information about the National Diffusion of Preoperative Frailty Screening and Prehabilitation can be found on the VA intranet at the VHA Marketplace Site

Principal Investigator

Daniel Hall, MD, MDiv, MHSc, is an investigator with the Center for Health Equity Research and Promotion, in Pittsburgh, PA.

Dr. Hall’s work has resulted in the following publications:

Nursing Unit Design and Hospital Falls

Nursing Unit Design and Hospital Falls



Each year, patient falls in US hospitals result in approximately 250,000 injuries and 11,000 deaths.  Due to their unique physical design and social characteristics, hospital nursing units can play a key role in reducing falls. Investigators in this study are examining physical and social nursing unit design factors that might contribute to, or prohibit, inpatient falls within VA care facilities. It is expected that study results will support effective, evidence-based nursing unit design both within and outside of VA facilities.

About the Study

Physician orders for patients at high risks for falls are often complicated by the opacity of nursing unit design. Patient rooms may appear to physicians as optimal in proximity, but from the nursing unit’s perspective, may be lacking in ease of access. In this study—which combines information from patient safety, data from the VA Informatics and Computing Infrastructure, floor-plan data, and qualitative interviews—investigators will:

  • Identify 50 VA medical-surgical nursing units with long-standing adjusted high and low statistical fall rates.
  • Compare design features in the 25 high- vs. low-fall units from floor plans (e.g., single vs. multiple room occupancy, corridor length) as well as patient visibility and accessibility using a mathematical technique called space syntax. 

Data from this study are currently being evaluated, findings are expected to be transmitted to the Office of Construction and Facilities Management (CFM)—which develops space, equipment, and planning Standards for all VA medical facilities. CFM will be updating standards for Inpatient Acute Care Nursing Units design in late FY21, and it is envisioned that results of this research showing a correlation between nursing unit layout and patient falls data will provide critical input into the conceptual Nursing Unit layouts being developed as part of this CFM standards update project. 

Principal Investigator

Ronald I. Shorr, MD, MS, is Director of the VA Geriatric Research Education and Clinical Center at the Malcom Randall VA Medical Center in Gainesville, FL.

Reducing Diagnostic Errors and Improving Patient Safety with Electronic Health Records

Reducing Diagnostic Errors and Improving Patient Safety with Electronic Health Records

©iStock/FG Trade

Dr. Hardeep Singh is a physician-investigator with the Center for Innovations in Quality, Effectiveness and Safety, in Houston, Texas. Dr. Singh has conducted extensive investigations into two main areas: 1) the safety and safe use  of VA’s electronic health record (EHR), including how EHR data can be used to improve safety, and 2) diagnostic errors. Some of the key findings from this work include:

  • EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after 'go-live' and institutions should build robust reporting and analysis capabilities to monitor and learn from them.
  • Currently implemented clinical decision support tools in EHRs may not be delivering expected benefits and positive impacts on safety.
  • Sociotechnical variability in how EHRs are implemented affects safety outcomes , and disregard of the nontechnical factors such as work flow, training, and organizational issues are a key concern.
  • Large scale EHR data can be used to measure and learn from diagnostic errors to improve safety. For instance, his team has used electronic trigger (e-trigger) tools to mine vast amounts of patient data to identify signals indicative of a likely diagnostic error or adverse event.
  • Formally incorporating patients’ perspectives and experiences with the diagnostic process can lead to a more comprehensive understanding of why diagnostic errors occur, and these data can be used to help develop strategies for mitigating those errors.

In this currently underway study, Measuring and Improving the Safety of Test Result Follow-Up , Dr. Singh and colleagues are developing a multi-faceted measurement approach designed to improve Veterans' outcomes related to follow-up of abnormal test results. Results from this project should improve Veterans’ health by reducing delays in care, and should also positively affect several VA national policy initiatives related to quality measurement and safety improvement.

Dr. Singh and colleagues are working with two VA operational partners—the VA National Center for Patient Safety and VA Office of Primary Care on this project. The project involves: 1) developing and pilot-testing a “change package” (SAFER Change Package) to provide VA facilities guidance on how to implement a surveillance and feedback program related to missed test results; and 2) evaluating whether the “SAFER TRACKS” Intervention can reduce missed results using a stepped-wedge cluster-randomized control trial. Investigators will also use a mixed-methods approach to evaluate the implementation of the SAFER TRACKS Intervention in order to determine strengths and challenges at participating sites.

Dr. Singh has published widely on the topic of patient safety, most recently in JAMA, with “A Roadmap to Advance Patient Safety in Abulatory Care”, and “Assessment of Health Information Technology–Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System”.

Improving Veteran Health by Increasing Dental Stewardship of Antibiotics and Opioids

Improving Veteran Health by Increasing Dental Stewardship of Antibiotics and Opioids



Antibiotics and opioids are the top therapeutic categories prescribed by dentists. VA provides a unique opportunity to study dental prescribing because of access to required ICD9/10 coding—which is rare in the private sector. This study is the first to utilize national VA databases to answer key questions on dental prescribing of antibiotics and opioids. Investigators expect that results will have far-reaching impact through the development of actionable findings for decisionmakers to improve evidence-based prescribing of antibiotics and opioids by VA dentists.

About the Study

Dentists prescribe one out of every ten prescriptions for both antibiotics and opioids in the US. Inappropriate use of these medications pose risks to patient safety, including the development of antibiotic resistant bacterial infections, as well as the danger of opioid addiction and overdose. Preliminary data on dental prescribing demonstrates that: 1) high prescribers of opioids are also high prescribers of antibiotics; and 2) over-prescribing of antibiotics and opioids is common among dentists. However, there remains a significant knowledge gap in the understanding of medication prescribing and over-prescribing by dentists within VA.

In this study, investigators are using both VA administrative data and one-on-one qualitative interviews with 'high' and 'low'-prescribing dentists at 'high' and 'low'-prescribing facilities to:

  • Asses perceptions of dental prescribing of antibiotics and opioid medications;
  • Identify characteristics associated with high rates of inappropriate prescribing;
  • Identify barriers and facilitators to the use of prescribing resources;
  • Describe dentists' attitudes toward prescribing antibiotics and opioids among those with high- and low-prescribing patterns in high- and low-prescribing facilities; and
  • Develop a pilot implementation study to improve dental prescribing.

This study is slated to conclude in June 2022, and final results are not currently available.

Principal Investigator

Katie J. Suda, PharmD, MS, is an investigator and Associate Director of Clinical Therapeutics with the Center of Health Equity Research and Promotion, in Pittsburgh, PA.


This study has resulted in the following publications:

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Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.