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Director's Letter

It has been almost 25 years since the National Academy of Medicine’s 1999 landmark report “To Err is Human” and the death of Josie King, a toddler who died due to medical errors in 2001, brought the issue of patient safety to the forefront. These and many other examples contributed to a national movement towards reducing harm, leading to the international adoption of the patient safety checklist, and overall improvements in patient safety.

This VA FORUM issue highlights VA research and clinical operations-driven initiatives focused on patient safety in anticipation of the 2024 National Patient Safety Awareness Week in March. VHA’s National Center for Patient Safety (NCPS) has focused on reducing or eliminating preventable patient harm in Veteran care, through a wide range of initiatives on suicide prevention, falls prevention, drug prescribing, and reduction of hospital-acquired infections. NCPS’s Patient Safety Centers of Inquiry (PSCIs) provide opportunities for researchers and operations leaders to work together to curate and improve national patient safety data and processes for VA patient safety goals to inform VA’s journey to high-reliability and a learning health system.

VA researchers featured in this issue have made prominent strides in patient safety research and improvements that address VA priority goals, notably in disseminating life-saving treatments for opioid overdose, prevention of antibiotic overuse and drug-resistant infections, and use of electronic “triggers” to better detect patient safety issues in the electronic health record. Looking ahead, HSR is poised to support the next generation of patient safety research by cultivating innovations in its foundational strategic methodology areas, namely implementation science, data science, systems science, science of partner engagement, and policy analysis. Notably, more research is needed in studying the impacts of change strategies to better implement and standardize new electronic health records and related technologies, especially in comparison to legacy systems. Greater standardization across EHRs, focus on interprofessional care, use of “closed loop” communication strategies, and implementation of quality improvement methods are areas of further research growth.

Looking ahead, VA researchers and operational partners are also poised to lead the next generation of patient safety research especially with the advent of artificial intelligence (AI). The explosion of new AI technologies that use machine learning, deep learning, and other methods offers much promise but also concern that overreliance on technology to solve patient health and safety issues may lead to unintended consequences. New federal guidance on Trustworthy AI calls for more rigorous study of new programs and policies to ensure AI optimizes Quintuple Aim goals to improve patient quality, safety, equity, access, experience, and value.