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  • High Acute Inpatient Psychiatric Bed Occupancy Associated with Increased Rates of Suicide among Veterans
    This study examined the relationship between the incidence of suicide among Veterans and acute inpatient psychiatric bed availability using occupancy as a measure of hospital strain and access. Findings showed that high acute VA psychiatric bed occupancy (>95%), not beds per capita, was associated with a 10% higher incidence of death by suicide. Extrapolated over the 6-year study across 145 hospital quarters with occupancy >95%, this hospital strain contributed to an estimated excess of 64.5 suicides. The absolute number of acute VA inpatient psychiatric beds decreased by 13% from 4,419 in 2011 to 3,860 in 2016, while mean occupancy decreased from 68% to 65% over the same time period; the number of deaths by suicide increased from 2,193 in 2011 to 2,464 in 2016. The VA national average of 65.5 acute psychiatric beds per 100,000 Veterans was three times the US national average of 22/100,000 in 2016. Changes in VA acute psychiatric beds, non-VA (i.e., community) psychiatric beds, spending on community mental health per capita, and the proportion of Veterans with a mental health diagnosis were not associated with the incidence of suicide among Veterans enrolled in VA care. Measuring hospital occupancy and establishing occupancy benchmarks should be included in patient safety reports as psychiatric bed overcrowding joins overall hospital, emergency department, and intensive care unit occupancy as a risk for higher mortality.
    Date: August 16, 2021
  • Need for Systemic, Multi-Level Interventions for Patient-Perpetrated Sexual Harassment in VA Healthcare Settings
    This study sought to identify challenges and stakeholder recommendations for addressing patient-perpetrated sexual harassment of women staff and patients at VA facilities. Findings highlight the complexity of addressing patient-perpetrated harassment and underscore the need for systemic, multi-level interventions. Perceived organizational-level challenges included a climate of tolerance for harassment, lack of formal policies, and insufficient leadership support. Perceived staff-level challenges included ambiguity around defining harassment, fear of negatively impacting patient-staff dynamics, and competing priorities. Study participants emphasized the need for greater education and training around harassment. Participants explained that some patients lack awareness and do not realize that their behaviors may be construed as harassing. Findings indicate an urgent need for clear, well-disseminated, action-oriented policies addressing how to report and/or intervene around patient-perpetrated harassment.
    Date: February 25, 2021
  • Veterans Open to Discussing Firearms Storage Safety in Primary Care Setting
    This quality improvement project – part of a larger study to develop a training program on firearms storage safety (FSS) for VA primary care teams – describes Veterans’ perspectives on discussing FSS during primary care visits. Most Veterans in the study agreed that primary care is an acceptable setting for FSS discussions, but staff need to build rapport and trust by using a personal, caring, and non-judgmental approach. Veterans noted concerns about the legal consequences of disclosing firearm ownership and most did not support direct questioning about this, e.g., “Do you own a firearm?,” which may trigger fears of having firearms being taken away or limitations being placed on access to firearms. Veterans also noted the need to provide a clear reason for why a discussion on FSS was happening, such as promoting mental health or concern for household safety and wellbeing. Discussing FSS with Veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts but must be conducted in a Veteran-centric manner.
    Date: January 26, 2021
  • JAMA Features Reflections on “Crossing the Quality Chasm” 20 Years Later
    This issue of JAMA includes two articles that reflect on the recommendations of the Institute of Medicine’s 2001 Crossing the Quality Chasm report that, 20 years ago, asked healthcare stakeholders to collaborate in order to provide care that is safe, effective, patient-centered, timely, efficient, and equitable. Both articles discuss how to make more progress toward these goals, while a third article from an HSR&D researcher is about the importance of patient safety in ambulatory care.
    Date: December 22, 2020
  • VA HIT-Related Outpatient Diagnostic Delays
    This study evaluated the role of health information technology (HIT) in the root cause analyses (RCAs) of outpatient diagnostic delays submitted to the VA National Center for Patient Safety, which leads patient safety initiatives and uses RCAs of adverse events and close calls to promote learning across the VA healthcare system. Findings showed that of the 214 RCAs included in this study, 88 involved HIT-related safety factors in diagnostic delays. In the majority of these RCAs (n=64), the primary process breakdown was due to inadequate follow-up of one or more abnormal test results. Delays involved the diagnosis of serious conditions, including cancers, infections, and cardiovascular disease. Most safety concerns (83%) involved problems with the safe use of HIT, mainly sociotechnical factors associated with workflow and communication, people, and a poorly designed human-computer interface. Five key high-risk areas for diagnostic delays emerged: 1) managing electronic health record inbox notifications and communication, 2) gathering diagnostic information, 3) technical problems, 4) data entry problems, and 5) failure of a system to track test results. Study findings suggest multiple interventions to reduce outpatient diagnostic delays through improved design, configuration, and use of HIT. Interventions should aim to: 1) Redesign EHR inboxes and message workflow; 2) Develop safety nets to identify missed results; 3) Improve the display of diagnostic information; 4) Track referrals; 5) Optimize order entry design; and 6) Pursue interoperability between VA and non-VA care settings.
    Date: June 25, 2020
  • Eight Organizational Target Areas for Improving Access to Primary Care
    This study sought to identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel. Findings showed that optimal access to primary care for enrolled patient populations requires active ongoing management of at least eight diverse target areas (two organizational structure targets, four process improvements, and two outcomes): 1) Clearly identified group practice management structure; 2) Interdisciplinary primary care site leadership; 3) Patient telephone access to ensure patient safety, scheduling, and coordination; 4) Contingency staffing (planned minimal excess staffing to cover routine absences); 5) Nurse management of demand through care coordination; 6) Proactive demand management by optimizing provider visit schedules; 7) Quality of patients’ experiences of access; and 8) Provider and staff morale in relationship to supply-demand mismatch (e.g., provider vacancies, panels exceeding recommended size).
    Date: February 1, 2020
  • Excess Medication Supply Potentially High among Veterans Using VA Healthcare
    This study sought to determine the prevalence of potential medication excess in the VA healthcare system – and to identify associated medication-, patient-, and system-level factors. Findings showed that medication excess was high among VA healthcare users in this study, with nearly two-thirds of patients (64%) experiencing at least one duplicative medication. Medication excess was more likely for Veterans with multiple prescribing providers or with higher comorbidity scores. Conversely, having a co-pay for medications was associated with lower rates of medication excess [a majority of patients (69%) did not have a co-pay]. Patients that had a combination of filling locations (CMOP or local pharmacy) and/or durations supplied had higher medication excess than those who had prescriptions from a single location or with uniform durations. As systems such as mail-order pharmacies and 90-day supply are increasingly implemented to reduce costs and improve medication adherence, it is important to recognize the potential for systems-level inefficiencies and inappropriate prescribing. Further efforts should be made to develop and implement strategies and systems (i.e., synchronized dispensing – refilling all prescriptions at the same time) that foster the appropriate and safe use of medications.
    Date: November 1, 2019
  • Unintentional Consequences of FDA Warnings: Varenicline
    This study examined the association between FDA drug safety communications and the use of varenicline (Chantix) – a prescription drug used to treat addiction to smoking. Investigators tracked varenicline and nicotine replacement therapy (NRT) prescribing and evaluated the potential consequences of decreased varenicline use on lost opportunities to assist patients with quitting smoking and health outcomes, including mortality. Within 12 months of FDA communications about a labeling change for varenicline, there was a 69% reduction in VA outpatient prescriptions and a 38% decrease in Medicaid prescriptions. Varenicline use reached its low point in VA in early 2014, when the number of unique quarterly users was 5,990, representing an 82% decline from the first quarter of 2008. In addition, from 2008 to 2018, NRT users in VA increased by 73%. One year after the 2016 publication of a study that showed no significant increase in psychiatric/behavioral effects with varenicline compared with NRT or placebo, quarterly varenicline use had increased by 43% in VA patients and by 26% in Medicaid patients. The number of VA patients who did not quit smoking due to decreased varenicline use was estimated to be 20,544, which likely was associated with negative health effects.
    Date: September 4, 2019
  • Lack of Awareness among VA Providers about Risk Associated with Prescribing Inhaled Corticosteroids to Veterans with COPD
    More than 50% of patients with mild-to-moderate COPD in the U.S. are prescribed inhaled corticosteroids despite recommendations to restrict use to patients with frequent breathing exacerbations. This study explored VA primary care providers’ experiences prescribing inhaled corticosteroids among Veterans with mild-to-moderate COPD. Of the Veterans with COPD in this study cohort, 15% were prescribed an inhaled corticosteroid. However, 61% of these prescriptions were not clinically indicated. Providers reported being unaware of current evidence and recommendations for prescribing inhaled corticosteroids; e.g., 46% of providers reported they were unaware of the risk of pneumonia. Providers also reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. Some providers expressed reluctance to change or stop prescribing if their patient was doing well. However, 52% of providers reported they would make an effort to reduce the use of inhaled corticosteroids, and 50% reported that they would make an effort to make greater use of alternative guideline-recommended medications. Study results corroborate prior findings that lack of awareness of current evidence-based guidelines is likely an important part of medical overuse. Efforts to expand access to care by increasing the number of prescribing providers a patient sees could make it more difficult to de-implement harmful prescriptions.
    Date: August 8, 2019
  • Dual use of VA and Medicare Drug Benefits Associated with Potentially Unsafe Medication Prescribing among Veterans
    Previous research shows that dual VA-Medicare Part D prescription drug use is a risk factor for potentially unsafe medication (PUM) exposure in Veterans with dementia and opioid users. Thus, this study evaluated the association of dual prescription use through VA and Part D (vs. VA-only use) with the prevalence of PUM exposure in a national cohort of dually-eligible older Veterans. Findings showed that dual use of VA and Part D prescription drug benefits was associated with an almost 2-fold increase in the odds of exposure to any PUM compared with VA-only use and more than 3 times the odds of exposure to severe drug-drug interactions. PUM exposure was lowest among VA-only users, and PUM exposure peaked in Veterans receiving prescriptions in near-equal proportions (50/50) from VA and Part D. To mitigate the potential risks associated with unsafe medication prescribing, policies intended to expand access to non-VA providers must ensure patient information is shared and integrated into routine practice for all patients seeking care across multiple healthcare systems.
    Date: July 22, 2019
  • State-based Prescription Drug Monitoring Programs Might Help Increase Opioid Prescribing Safety among Veterans Using VA and Non-VA Healthcare
    This study evaluated VA physicians’ perspectives and experiences regarding the use of state-based Prescription Drug Monitoring Programs (PDMPs) to monitor Veterans’ receipt of opioids from non-VA prescribers. Findings showed that VA primary care physicians broadly embraced PDMPs as a tool to monitor Veterans’ receipt of opioids from non-VA sources despite identifying multiple barriers to optimal use. They also identified several key best practices currently used within VA and made suggestions for future improvements that may enhance efforts to ensure safe opioid prescribing. Key barriers included incomplete or unavailable prescribing data, while key facilitators included linking PDMPs with VA’s electronic health record, using templated notes to document PDMP use, and delegating routine PDMP queries to ancillary staff (i.e., nurses or clinical pharmacists). Applying improvements identified in this study may enable VA to serve as a national model for those seeking to enhance PDMP use, thereby improving opioid prescribing safety.
    Date: March 8, 2018
  • Journal Features VA Research on Combating Multi-drug Resistant Organisms Posing Public Health Threat
    As an integrated healthcare system with acute care, community living centers, and community-based outpatient clinics, VA provides an ideal setting in which to study multi-drug resistant organism prevention and make a significant impact. Thus, a group of HSR&D infectious disease researchers and operations partners convened in Iowa City, IA, in September 2016. Conference participants included experts in hospital epidemiology, antimicrobial stewardship, medical anthropology, clinical medicine, infection prevention, pharmacy, and sociology. The participants were divided into four subgroups, to work together to identify key knowledge gaps and important targets for future investigation. Articles resulting from this collaboration are highlighted in this journal issue.
    Date: February 8, 2018
  • VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans
    This study examined changes associated with Opioid Safety Initiative (OSI) implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Findings showed that during the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens, with an overall reduction of 16% among Veterans receiving >100 morphine-equivalent milligrams (mEq) daily dosages and 24% among Veterans receiving >200 mEq. There was a 21% reduction in Veterans receiving benzodiazepines concurrently with opioids. Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing). The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients.
    Date: January 4, 2017
  • Safety Risk for Veterans Receiving Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions from VA and Medicare Part D
    Ensuring safe buprenorphine prescribing is especially challenging for VA, which treats a substantial number of Veterans with chronic pain and opioid use disorder, as well as an increasing number of patients who receive concurrent care in the private sector (i.e., Medicare Part D). This study identified Veterans dually enrolled in VA and Medicare Part D who filled a buprenorphine prescription in 2012 from either healthcare system and identified the proportion of Veterans with overlapping prescriptions from either system. Findings showed that more than one in four Veterans who received a VA prescription for buprenorphine – and one in five Veterans who received a Medicare prescription for buprenorphine – also received overlapping prescriptions for opioids from a different healthcare system. Among Veterans receiving buprenorphine from VA, 1% received an overlapping benzodiazepine prescription from Medicare, while among those receiving buprenorphine from Medicare, 16% received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients who had cross-system opioid overlap, 25% and 35%, respectively, had >90 days of overlap. Findings indicate a previously undocumented safety risk for Veterans dually enrolled in VA and Medicare who are receiving prescriptions for buprenorphine and overlapping prescriptions for opioids and/or benzodiazepines.
    Date: December 7, 2016
  • Application of Triggers on VA “Big Data” may Help Identify Patients Experiencing Delays in Diagnostic Evaluation of Chest Imaging
    Triggers offer one method to use big electronic health record (EHR) data to prevent and mitigate the impact of delays in care related to missed test results. Triggers consist of computerized algorithms that can scan thousands of patient records to flag those with clues suggestive of patient safety events. This study tested the application of a trigger within VA’s EHR to help identify delays in patient follow-up related to abnormal chest imaging results. Findings showed that the trigger identified delays in patient follow-up with a reasonable accuracy for use in the clinical setting, suggesting that triggers are able to identify almost all delays related to abnormal lung imaging follow-up, and cost-effectively minimize the amount of effort providers spend reviewing false-positive results.
    Date: September 1, 2016
  • Impact of New Institute of Medicine Report on Patient Safety
    The authors of this NEJM article discuss why the topic of diagnostic error is timely and suggest next steps to translate the Institute of Medicine recommendations into action.
    Date: December 24, 2015
  • Consequences of Notifying VA Patients about Potential Exposure to Large-Scale Adverse Events
    This study sought to determine the intended and unintended consequences of patient notification following a large-scale adverse event (LSAE) within the VA healthcare system, which systematically looks for LSAEs, tracks potentially exposed patients, and communicates with them after LSAE notification. Findings showed that more than two-thirds of potentially exposed patients returned for HCV, HBV, and HIV testing following the receipt of an LSAE notification letter, which was associated with a 72 to 76 percentage point increase in testing. Among Veterans who sought testing, 57% were tested in the 30 days following notification, and 74% were tested within 60 days. The vast majority (>98%) completed testing in a VA facility; less than 2% were tested at a non-VA facility paid by purchased care or Medicare (when eligible). Among older Veterans, notification was associated with higher odds of increased VA outpatient use in the following 3 months, but decreased odds of using VA healthcare in the subsequent 9 months. Compared to white Veterans, African American Veterans were significantly less likely to return to VA for follow-up testing.
    Date: May 1, 2015
  • Home Safety Intervention Improves Caregiver Competence for Individuals with Alzheimer’s Disease
    This trial sought to give informal caregivers the knowledge and resources to prevent risky behaviors and accidents in the homes of persons with dementia of the Alzheimer’s type (DAT) or a related dementia. Investigators designed a Home Safety Toolkit that includes a booklet on high-frequency/high-severity risks for accidents and injuries in the home, and sample items (i.e., smoke alarm, night lights, slide bolt lock, medicine case) that allow caregivers to make easy home safety modifications. Findings showed that all outcome variables improved more for caregivers in the Home Safety Toolkit intervention group than for caregivers in the control group. For example, caregivers in the intervention group had significantly improved home environmental safety compared to those in the control group, and patients in the intervention group had fewer risky behaviors and accidents compared to patients in the control group. The intervention group had 80% overall confidence in their ability to make a home safer compared to 75% for caregivers in the control group. Caregivers in the intervention group also had lower perceived strain in caregiving compared to caregivers in the control group.
    Date: October 1, 2013
  • Patient Safety Issues in VA Outpatient Setting
    This retrospective study analyzed 111 root-cause analysis reports that investigated delays in the VA outpatient setting that were submitted to VA’s National Center for Patient Safety from 2005 to 2012. Findings showed that most outpatient delays arose from multiple dimensions of ambulatory care processes and involved a large number of contributory factors. Most contributory factors were related to communication and coordination among providers, non-providers (i.e., clerical and admin support staff), and patients. Failures in the process of follow-up and tracking of Veterans were especially prominent, mentioned in more than half of the reports. The 111 reports examined in this study were associated with 478 recommended actions, of which the most common were related to staff training and education; changes to policy or procedure; and standardization of processes through protocols, clinical guidelines, or order sets.
    Date: August 1, 2013
  • Journal Issue Highlights Patient Safety Strategies
    For the past four years, a project team that includes HSR&D investigators and other academic researchers, along with an international panel of 21 stakeholders and evaluation methods experts, conducted an evidence-based assessment of patient safety strategies (PSSs). This Annals of Internal Medicine special supplement presents review results for 10 of the patient safety strategies.
    Date: March 5, 2013
  • Framework for the Development of Electronic Health Record-Specific Patient Safety Goals
    Recent evidence has highlighted significant and often unexpected risks resulting from the use of electronic health records (EHRs) and other health information technology. A coordinated, consistent, national strategy is needed to address the safety issues posed by EHRs, as well as improving healthcare safety in the context of technology use. This article proposes a new three-phase framework for the development of EHR-specific patient safety goals.
    Date: November 8, 2012
  • Promoting Gun Safety and Delayed Gun Access to High-Risk Patients is Acceptable to Veterans and Providers
    This study explored VA stakeholders’ perceptions about gun safety and interventions to delay gun access among Veterans with a mental health diagnosis during high-risk periods. Findings showed that several measures to promote gun safety and to delay access to guns for high-risk patient groups are acceptable to VA patients and providers, if judiciously applied. For example, most patients and clinicians in this study indicated that routine screening for gun access was acceptable, particularly for patients receiving mental healthcare. Clinicians and patients reported having very little discussion regarding gun ownership during the course of routine treatment. Both groups indicated that gun access was typically discussed only during suicide or homicide risk assessments, and then only if the patient expressed suicidal/homicidal ideation that involved guns. However, nearly all patients felt that clinicians should routinely speak to their patients about guns. One of the most widely suggested and accepted interventions – across all stakeholders – was further education on suicide, including risks related to guns, for VA patients, family members, and clinicians.
    Date: September 5, 2012
  • VA Communication and Information Sharing During H1N1 Influenza Pandemic
    This study assessed information sources and communication provided to VA facility infection control departments, and how these departments disseminated information to facility staff during the 2009 H1N1 influenza pandemic. Communication was facilitated when information was timely, organized, disseminated through multiple channels, and included educational materials. Barriers to effective communication included feeling overwhelmed by the amount of information received, encountering contradictory information, and restrictions on information dissemination due to uncertainty and inconsistent information. Participants offered recommendations for future pandemics, including the need for: standardized educational content, clearer guidance from national organizations, and pre-defined communication plans for hospital staff. The authors suggest that these findings can be used in planning for future pandemics and other emergent situations.
    Date: June 23, 2012
  • Patient Safety Indicators Do Not Always Identify True Safety Events in VA Hospitals
    This study examined the positive predictive value (PPV: proportion of flagged cases confirmed by chart review to have PSI event) of 12 selected PSIs using data from VA’s electronic medical record as the gold standard. Findings showed that despite evidence on the accuracy and completeness of VA data, all PSIs misidentified true events to some extent, with considerable PPV variation across PSIs. PPVs ranged from 28% for post-operative hip fracture to 87% for post-operative wound dehiscence. This variation was due to coding inaccuracies or limitations (e.g., lack of precise or meaningful codes, poor documentation). PSI rates were generally low. Ulcer and respiratory failure were the most commonly flagged PSIs, suggesting clinical areas for targeting and opportunities for hospital improvement. VA PSI rates will be reported on both the VA and CMS Hospital Compare websites in the near future. However, results suggest that additional coding improvements are needed before the PSIs evaluated in this study are used for hospital reporting or pay-for-performance.
    Date: January 1, 2012
  • Article Recommends Role of “ Patient Safety Professional” to Increase Patient Safety
    This article recommends consideration of a new type of clinical role in the hospital setting – the Patient Safety Professional (PSP) – to ensure that each patient receives individualized prevention strategies to minimize the hazards of hospitalization. Authors suggest the PSP be an advanced practice registered nurse, who would: 1) assess assigned patients for hospital-acquired complications (e.g., pressure ulcers, falls, pain) following explicit protocols relevant to a short list of safety targets; 2) prioritize identified complications based on morbidity, mortality, and hospital costs; and 3) develop and implement plans to decrease hospital-acquired complications, in consultation with physicians and staff nurses. The PSP might also provide additional benefits to the organization, i.e., he/she could serve as an educational resource or consultant to other clinicians and take responsibility for staying up to date on new advances and recommendations in the area of patient safety.
    Date: September 8, 2011
  • Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
    This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
    Date: August 24, 2011
  • Medication Reconciliation Reduces Adverse Drug Events Related to Some Hospital Admission Prescribing Changes
    This study estimated the effectiveness of inpatient medication reconciliation at the time of hospital admission on adverse drug events (ADEs) caused by admission prescribing changes. Findings showed that medication reconciliation at the time of hospital admission reduced ADEs caused by admission prescribing changes that were classified as errors by 43%, but it did not reduce ADEs caused by all admission prescribing changes. Non-error-related ADEs would not be averted by one-time medication reconciliation on admission, but they might be averted by improved provider awareness and monitoring of admission prescribing changes during the hospital stay. The potential impact of such an intervention is large, as 50% of the ADEs in this study were caused by admission medication changes that were not errors.
    Date: May 9, 2011
  • Electronic Health Information’s Effect on Clinical Workflow
    This study sought to assess aspects of health information technology (HIT) that impact clinical workflow – and to identify a set of HIT characteristics that support patient care processes. Investigators identified many examples of how HIT affects workflow, but characteristics were strongest within four primary domains: 1) Trustworthy and reliable (e.g., inconsistent incomplete, incorrect information in the electronic health record (EHR); 2) Ubiquitous (e.g., poor accessibility due to lack of computer workstations or lengthy secure login processes, but good information availability ); 3) Effectively displayed (e.g., problems locating scanned documents in the EHR, lack of searchability , information not well-organized or prioritized); and 4) Adaptable to work demands (e.g., EHR is not portable or customizable, difficult to modify information). The findings from this study underscore the value of obtaining input from healthcare employees and may be used to enhance HIT design, clinical practice, and patient safety.
    Date: December 1, 2010
  • Threshold for Glycemic Control among Veterans with Diabetes
    In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
    Date: October 1, 2010
  • Patient-Centered Medical Homes Could Reduce Medical Errors
    The patient-centered medical home (PCMH) can potentially address many current safety concerns in primary care, including what is likely the leading type of error – diagnostic error (i.e., missed, delayed, or wrong diagnosis). Integral to the PCMH concept are electronic medical records (EHRs), which can enhance access to data and advanced decision support to reduce diagnostic error. However, as currently envisioned, many PCMH models may not address other systems and cognitive problems that cause diagnostic errors. In this Commentary, authors recommend five “rights” for reducing diagnostic errors in future patient-centered medical homes within and outside VA. The five “Rights” include: Right Teamwork, Right Information Management, Right Measurement and Monitoring, Right Patient Empowerment, and Right Safety Culture.
    Date: July 28, 2010
  • Checklist Successfully Identifies VA Environmental Hazards for Inpatient Suicide
    This is the first study to examine the implementation and effectiveness of the Mental Health Environment of Care Checklist to improve patient safety. Findings show that between 2007 and 2008, 7,642 environmental suicide hazards had been identified and 5,834 (76.3%) had been abated. Approximately 2% of these suicide hazards were identified as critical, and another 27% were rated as serious. The most common hazard was anchor points for hanging (44%); anchor points also presented the greatest risk level, followed by suffocation and poison. High-risk locations included bedrooms and bathrooms.
    Date: February 1, 2010
  • “Rights” of Safe Electronic Health Record Use
    This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
    Date: September 9, 2009
  • Resident Duty Hour Reform has No Systematic Impact on Patient Safety in Teaching Hospitals
    This observational study focused on patients admitted to VA and Medicare acute-care hospitals, examining changes in patient safety events in more vs. less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform. Findings show that the implementation of duty hour regulations did not have an overall systematic impact on potential safety-related events in either VA or non-VA (Medicare) hospitals of different teaching intensity. In the few cases where there were statistically significant increases in the relative odds of developing a patient safety event, the increases were too small to be clinically meaningful.
    Date: July 1, 2009
  • Computerized Patient Hand-Off Tool Shows Promise in Increasing Patient Safety
    Clinicians at the Indianapolis VAMC use a computerized patient hand-off tool (PHT) that extracts information from the electronic health record to populate a form that is printed and given to the cross-over physician. This study sought to: 1) evaluate the rate at which data were extracted from VA’s electronic medical record into the PHT; 2) assess the frequency for needing information beyond that contained in the PHT; and 3) assess physicians’ perceptions of the PHT, as well as opportunities for improvement. Overall, findings show that the PHT reliably extracts information from the electronic health record. However, while patient identifiers and medications were reliably extracted (>98%), other types of information were more variable (e.g., allergies and code status, <50%). Residents preferred PHT content that included: patient medication list, assessment and plan from the most recent physician note, and list of anticipated problems and recommendations for treatment. The primary suggestion for improving the PHT form was that it be organized by patient location (e.g., ward patients grouped together). Authors suggest that the PHT, which is marked for dissemination to other VAMCs, has considerable potential for improving patient safety.
    Date: July 1, 2009
  • Application of Aviation Duty-Hour Restrictions to the U.S. Healthcare System would be Cost-Prohibitive
    Restricting resident work hours has been identified as a potential mechanism to improve patient safety. One approach to reform has been to model guidelines and standards after the aviation industry. This study sought to evaluate the cost and workforce implications of applying aviation duty-hour restrictions to the entire practicing physician workforce. Findings show that the application of aviation duty-hour restrictions to the U.S. health care system would be cost-prohibitive. Adopting aviation guidelines would create a deficit of 166,835 residents at a cost of approximately $6.45 billion per year. The application of aviation standards for duty-hour restrictions and rest time requirements to actively practicing physicians creates even larger deficits. To correct the work-hours deficit created through widespread adoption of aviation industry standards would require 459,198 physicians at a cost of approximately $80.4 billion per year. Implementing a mandatory retirement age would cost an additional $10.5 billion.
    Date: June 1, 2009
  • Improving Patient Safety in Teaching Hospitals by Modifying Residents' Work Hours
    The authors propose 8 guiding principles and note that work schedule reform should use the best scientific evidence to devise an optimal system.
    Date: September 10, 2008
  • VA Nurse Burnout and Patient Safety Outcomes
    Among VA nurses at one Midwestern location, burnout was associated with perceptions of a less safe environment. While burnout was not associated with event-reporting behavior, it was negatively associated with reporting of near misses (mistakes that did not lead to adverse events). The finding that higher burnout was associated with lower incidence of near-miss reports is of concern because these reports are essential to addressing safety concerns in the environment.
    Date: August 1, 2008
  • Improving the Environment of Care to Reduce Inpatient Suicide and Suicide Attempts in VA Facilities
    Authors provide 5 recommendations for reducing environmental hazards for suicide on inpatient psychiatric units.
    Date: August 1, 2008

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