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
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Citations
(5 of more than 279 PATIENT SAFETY focused publications)
- Singh H, Sittig DF, Classen DC. Maximizing the Ability of Health IT and AI to Improve Patient Safety. JAMA internal medicine. 2024 Oct 28.
- Singh H, Senay E, Sherman JD. Lessons from patient safety to accelerate healthcare decarbonization. Journal of hospital medicine. 2024 Sep 17.
- Sullivan JL, Shin MH, Ranusch A, Mohr DC, Chen C, Damschroder LJ. A Mixed Methods Study Exploring Patient Safety Culture at Four VHA Hospitals. Joint Commission Journal on Quality and Patient Safety. 2024 Nov 1; 50(11):791-800.
- White AT, Vaughn VM, Petty LA, Gandhi TN, Horowitz JK, Flanders SA, Bernstein SJ, Hofer TP, Ratz D, McLaughlin ES, Nielsen D, Czilok T, Minock J, Gupta A. Development of Patient Safety Measures to Identify Inappropriate Diagnosis of Common Infections. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2024 Jun 14; 78(6):1403-1411.
- Sullivan JL, Shin MH, Chan J, Shwartz M, Miech EJ, Borzecki AM, Yackel E, Yende S, Rosen AK. Quality improvement lessons learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook". Health services research. 2024 Dec 1; 59 Suppl 2(Suppl 2):e14317.
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Publication Briefs
(5 of more than 39 PATIENT SAFETY focused 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
( 5 of more than 27 PATIENT SAFETY focused projects
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| Project No. |
Title |
PI |
Funding Start |
| PPO 20-148
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Promoting Antimicrobial Stewardship and Patient Safety by Implementing Interventions to Evaluate and Delabel Penicillin Allergy |
Kakumanu, Sujani |
2021-05-01 |
| RRP 11-379
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Off-Label Use of Antipsychotics: Determinants and Impact on Patient Safety |
Hudson, Teresa |
2012-07-01 |
| RRP 11-022
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How to Interpret and Use Patient Safety Indicator (PSI) Reports |
Shin, Marlena |
2011-10-01 |
| NRI 10-124
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Improving Patient Safety: Context and Nurses' Work Processes for Pressure Ulcers |
Soban, Lynn |
2011-06-01 |
| CDA 09-024
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Circumventing Health IT: Identifying Patient Safety Risks |
Saleem, Jason |
2009-10-01 |
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HSR Briefs, Reports, Newsletters
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