Patient Safety
In healthcare settings, “patient safety” refers to the assurance that patients and their clinical environments are not vulnerable to inadvertent harm. VA has a long-standing commitment to patient safety, and in 2019 made an enterprise-wide commitment to become a high-reliability organization (HRO) and achieve “Zero Harm.”
HSR patient safety research has two crucial priorities: first, identifying the patterns, frequencies, and root causes of adverse events and near misses across VA healthcare. Second, creating and evaluating evidence-based interventions that protect Veterans from preventable harm, including falls, medication errors, healthcare-acquired infections, surgical complications, and diagnostic failures. Researchers also examine organizational factors that shape safety outcomes, working to cultivate environments where error reporting and prevention become standard practice.
Each section below is populated by a search of the HSR website. Search results are generated based on the search term "Patient Safety" . Results are updated as new data are available.
VIEW: Citations | Publication Briefs | Studies | HSR Briefs, Reports, Newsletters | Cyberseminars | Videos | Podcasts | Other Resources
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Citations
(recent PATIENT SAFETY publications)
- Sullivan JL, Miech EJ, Shin MH, Chan JA, Shwartz M, Borzecki A, Abdulkerim H, Yackel E, Yende S, Rosen AK. Explaining site-level fidelity within a national initiative to implement a VA patient safety guidebook: the difference-making role of networks & communications. Implementation science communications. 2025 Nov 27 DOI: 10.1186/s43058-025-00797-8.
- Nessen SJ, Friedman AB, Bhananker AR, Muir KJ, Chary AN. Waiting room and hallway care for older adults: a qualitative study with emergency nurses and technicians. BMC geriatrics. 2025 Nov 26; 25(1):970, DOI: 10.1186/s12877-025-06384-9.
- Randa SN, Nouri S, Walling AM, Patel K, Cheng MKW, Ritchie CS, Li B, Vanegas G, Cardoso E, Sudore RL. Errors in Electronic Health Record Advance Care Planning Documentation: It's a Patient Safety Issue. Journal of palliative medicine. 2025 Nov 17 DOI: 10.1177/10966218251395440.
- Golenbock SW, Basnet D, Mull HJ, Lamkin R, Harvey K, Shin M, Strymish JM, Leatherman S, Ferguson R, Branch-Elliman W. Development of a feasible and portable electronic flag for near-real-time identification of renal replacement therapy in the Veterans Health Administration. Antimicrobial stewardship & healthcare epidemiology : ASHE. 2025 Oct 23; 5(1):e279, DOI: 10.1017/ash.2025.10166.
- Roos R, Zwaan L, Maranus M, Meynaar IA, Valk VJ, van Nieuwkoop C, Kamps GJ, Singh H, van Aken MO. A Safety-II approach to learn from practice variation in the diagnostic process in the emergency department: an action research study. Diagnosis (Berlin, Germany). 2025 Oct 13 DOI: 10.1515/dx-2025-0087.
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Publication Briefs
(recent PATIENT SAFETY Publication Briefs )
- QUERI Evaluation Identifies Barriers, Facilitators, Lessons Learned, and Strategies to Better Standardize Veteran Safety Practices Across VA and Community Care
VA’s “Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook” was designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., community care). This project identified organizational barriers and facilitators related to Guidebook implementation, identified lessons learned during implementation, and developed strategies to improve f...
Date: May 8, 2024
- 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 hospit...
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 harass...
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...
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 arti...
Date: December 22, 2020
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Studies
(recent PATIENT SAFETY projects
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| Project No. |
Title |
PI |
Funding End |
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CDA 22-078
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Applying high-reliability organization principles to home care to enhance patient safety |
Quach, Emma |
2028-09-30 |
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RCS 23-082
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HSR&D Research Career Scientist Award |
Taylor, Stephanie |
2028-09-30 |
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IIR 23-061
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Evaluating the Impact of Medical Foster Home Coordinator Effort and Experience on Costs |
Intrator, Orna |
2027-12-31 |
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HSR2-017-24W
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Engaging primary care nurses and Veterans to develop and test processes to identify and assist Veterans with unmet social needs |
Kamdar, Nipa |
2027-12-31 |
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IIR 22-173
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Ensuring Safe and Effective Delivery of Outpatient Parenteral Antimicrobial Therapy for Veterans |
Harrod, Molly |
2027-11-30 |
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HSR Briefs, Reports, Newsletters
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