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VA Health Systems Research

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Research Topics

Patient Safety

The role of patient safety research is to understand how best to ensure that patients, their clinical environments, and their clinical processes and systems are safe—and not vulnerable to causing inadvertent harm. VA health services investigators conduct research into patient safety that encompasses everything from appropriate patient identification processes to preventing hospital-acquired infections to assessing clinical and organizational leadership attitudes.

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


(5 of more than 271 PATIENT SAFETY focused publications)

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Publication Briefs

(5 of more than 38 PATIENT SAFETY focused publication briefs)

  • 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
  • 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 invol...
    Date: June 25, 2020

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( 5 of more than 27 PATIENT SAFETY focused projects )

Project No.  Title  PI  Funding Start   
PPO 20-148 Promoting Antimicrobial Stewardship and Patient Safety by Implementing Interventions to Evaluate and Delabel Penicillin Allergy Kakumanu, Sujani 2021-05-01
RRP 11-379 Off-Label Use of Antipsychotics: Determinants and Impact on Patient Safety Hudson, Teresa 2012-07-01
RRP 11-022 How to Interpret and Use Patient Safety Indicator (PSI) Reports Shin, Marlena 2011-10-01
NRI 10-124 Improving Patient Safety: Context and Nurses' Work Processes for Pressure Ulcers Soban, Lynn 2011-06-01
CDA 09-024 Circumventing Health IT: Identifying Patient Safety Risks Saleem, Jason 2009-10-01

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The most recent "Patient Safety" seminars are displayed.

Date Title Presenter(s)
5/23/2024 The Surgical Pause: Measuring Frailty and Doing Something About It Hall, Daniel  
4/20/2022 Electronic Triggers to Monitor Patient Safety in Primary Care Hagan, Scott  
12/14/2021 Speaking Up for Patient Safety: It’s Complicated Gilmartin, Heather  
9/21/2021 Using PowerBI to Accelerate National Implementation of Evidence-based Practices Dhruva, Sanket  
Schmajuk, Gabriela  
Kaltenbach, Tonya  
Whooley, Mary  
2/25/2021 Leveraging VA Text Note Data for Quality Measurement: A Case Study of a Novel Measurement Tool for Cardiac Device Procedures Branch-Elliman, Westyn  
Mull, Hillary  

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Other Resources

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