2001 Winner; 2000 Finalist
Winners:
Veterans Health Administration, US Department of Veteran Affairs
2000
Publication:
Innovations in American Government Awards
Sponsored By:
Innovations in American Government Awards
Jurisdiction:
US Department of Veteran Affairs

Preventable medical errors are estimated to cause as many as 98,000 deaths a year nationally, exceeding those attributed to motor vehicle accidents, breast cancer or AIDS. Based on the premise that such errors are frequently the result of flawed systems, not careless people, the Veterans Health Administration (VHA) of the US Department of Veteran Affairs has developed and implemented the National Center for Patient Safety (NCPS). This "systems approach" to error reduction was designed to reduce avoidable deaths and injuries within VHA's 173 medical centers, which receive 41 million outpatient visits and care for 700,000 inpatients yearly.

A cornerstone of this patient safety program is the emphasis on prevention, not punishment. Building on lessons learned in the aviation- and nuclear power-safety industries, the program aims to reduce adverse events by focusing on system weaknesses instead of assigning blame to individuals. In addition to drawing on practices of the safety industry, NCPS is informed by the field of human factors design and usability, in which environments are designed to enhance human performance.

NCPS relies on a standardized reporting system operated by NASA; it is modeled after the Aviation Safety Reporting System that NASA runs for the Federal Aviation Administration. Reporting of vulnerabilities, errors and "close calls" is voluntary, confidential, and non-punitive. (Intentionally unsafe acts are excluded from confidentiality requirements). In the first 16 months of the program, the rate of untoward incidents reported increased 30-fold and close-call reporting increased 900-fold.

This increase in events reported in not a reflection of a rise in the number of events, but is the result of the "culture of safety" that NCPS has promoted. In this new atmosphere, employees are made to feel safe reporting errors and are encouraged to recognize that injury prevention is everyone's responsibility.

Patterns of problems at different facilities are identified through Root Cause Analysis, a rigorous method for determining the real reason why a mistake occurred. Root Cause Analysis teams at each of the VHA facilities formulate solutions and share findings nation-wide. One solution devised from this system is the use of bar-code scanner technology. To avoid medication mix-ups, bar-code scanners are used when medications are administered to patients to verify that the right patient is receiving the right drug in the right dose at the right time. At the Baltimore VA Medical Center the number of medication errors fell from 103 in 1999 to 57 in 2000 after bar coding was introduced.

NCPS is the first comprehensive systems-oriented safety program devised for a large medical organization. By attempting a profound shift from a "culture of blame" to a "culture of safety" and examining underlying causes of medical errors in order to prevent future occurrences, the VHA has made substantial progress in providing safe care to American veterans.

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