• Pimentel CB, Pimentel MPT, Hartmann CW. Medical safety huddles to engage frontline physicians in patient safety: calling physicians back to the table. BMJ quality & safety. 2023 Sep 15.
• Grant R, Benamouzig D, Catton H, Cheng VC, Dhingra N, Laxminarayan R, Legido-Quigley H, Martinez SL, Marikar K, Mendelson M, Parneix P, Perencevich E, Singh H, Tschudin-Sutter S, Ushiro S, Wesangula E, Gardiol C, Dziekan G, Harbarth S, Pittet D. COVID-19 pandemic: a catalyst for accelerating global action on patient safety. The Lancet. Infectious diseases. 2023 Oct 1; 23(10):1108-1110.
• Zimolzak AJ, Singh H, Murphy DR, Wei L, Memon SA, Upadhyay DK, Korukonda S, Zubkoff L, Sittig DF. Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites. BMJ health & care informatics. 2022 Jul 1; 29(1).
• Kim B, Grech SM, Rembisz AE, Pinkerson AI, Topor DR, Ramirez DM, Budson AE, Funk MC. Development and Pilot of a Process for Regularly Sharing Summary Patient Safety Data. Academic Psychiatry : The Journal of The American Association of Directors of Psychiatric Residency Training and The Association For Academic Psychiatry. 2023 Feb 1; 47(1):53-58.
• Mohr DC, Chen C, Sullivan J, Gunnar W, Damschroder L. Development and Validation of the Veterans Health Administration Patient Safety Culture Survey. Journal of Patient Safety. 2022 Sep 1; 18(6):539-545.

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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 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

» View more Publication Briefs

» View more Studies

• A Patient-Centered Intervention to Improve Opioid Safety || In Progress

  A Patient-Centered Intervention to Improve Opioid Safety...2016 In this Issue: Improving the Safety of Prescription Opioid Use among Veterans...Contents A Patient-Centered Intervention to Improve Opioid Safety Ongoing Study

• Interventions to Support Caregivers or Families of Patients with TBI, PTSD, or Polytrauma: A Systematic Review

  Support Caregivers or Families of Patients with TBI, PTSD, or Polytrauma: A Systematic...Support Caregivers or Families of Patients with TBI, PTSD, or Polytrauma: A Systematic...OR "family-inclusive"[tiab]) OR (("Patient Care"[Mesh] OR "Caregivers"[Mesh]

• high-reliability-org.pdf

  Implement effective services to improve patient outcomes and to support VA clinical................. 17 ACHE Culture of Safety Organizational Self-Assessment Tool

• Secure Messaging between Providers and Patients, and Patients’ Access to Their Own Medical Record

  Messaging between Providers and Patients, and Patients’ Access to Their Own Medical...Messaging between Providers and Patients, and Patients’ Access to Their Own Medical...Messaging between Providers and Patients, and Patients’ Access to Their Own Medical

• Effects of VHA Opioid Policy on Prescribing and Patient Outcomes || In Progress

  In 2013, VA launched the Opioid Safety Initiative (OSI), the first of several...2018 In This Issue: Improving Opioid Safety » Table of Contents Effects of VHA...VHA Opioid Policy on Prescribing and Patient-Centered Outcomes Feature Article

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» View more Cyberseminars

Videos

• Less is More—Kicking CAUTI and Preventing Antibiotic Resistance 12/26/19
• From Research to Policy—Making Medications Safer for Veterans 12/17/19
• Medication Safety to Improve Depression Care 02/27/17

Podcasts

• Evaluating Clinician Experiences with VA Electronic Health Record Modernization 07/25/2022
• Partnering to Increase Veteran Safety: Fall Prevention and Nursing Unit Design 10/25/2021

Other Resources

• Visit the VHA National Center for Patient Safety to learn more about efforts to ensure that Veterans receive safe, high-quality care.
• Learn more about the HSR&D-funded projects in the Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) initiatives for safety and quality and infection prevention.