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Programs and Initiatives
NCPS Programs and Initiatives
Patient Safety Training
NCPS has developed an inclusive patient safety training program attended by more than 2,070 VA caregivers at the 28 sessions conducted since November 1999. Professionals from 12 foreign countries and 279 U.S. health care institutions/agencies have also attended.
Learn more: Contact us via email for further information
Tool Kits and Cognitive Aids
Human factors-oriented tool kits have been developed by NCPS to promote patient safety while enhancing the user’s awareness of the importance of developing a culture of safety.
A wide range of cognitive aids were also created to further reduce the risk of causing inadvertent harm to patients.
Learn more: NCPS Publications
Medical Team Training (MTT)
The MTT program was developed to improve patient care outcomes through more effective communication and teamwork among providers.
When staff members reviewed 5,511 root cause analysis reports, 78 percent of the cases identified communication failure as a root cause contributing factor in the reported adverse event or close call.
MTT staff members have conducted 109 Learning Sessions that have involved 83 facilities and targeted nearly 7,500 caregivers.
Learn more: Medical Team Training
Alerts and Other Publications
NCPS publishes safety alerts or advisories on specific issues relating to equipment, medications and procedures that might cause harm to patients.
Topics in Patient Safety® (TIPS) is a bimonthly newsletter that is also published by NCPS and discusses a wide range of patient safety issues.
Learn more: Publications and Alerts and Advisories
Curriculum Development
Realizing that the place to begin learning about patient safety is during early training, in 2002, NCPS began working with physicians and patient safety personnel from VA medical centers and affiliated universities to develop and test a patient safety curriculum program for residents. From this, faculty workshops were developed.
Nearly 500 attendees from more than 70 VA hospitals and 45 university affiliates, the attendees have included professionals from 42 states and six countries: Canada, Japan, Netherlands, United Kingdom, Australia, and South Africa.
Learn more: Curriculum Development
Patient Safety Fellowship Program
NCPS and the VA Office of Academic Affiliations (OAA) and have teamed to offer one-year fellowships in patient safety. Proposals were generated and sites identified during 2005-2006; eleven fellows began the program in July 2007. Funding is provided by OAA.
The fellowships offer post-residency trained physicians and post-doctoral or post-masters-degree-trained associated health professionals (such as nurses, psychologists, and health care administrators) in-depth education in patient safety practice and leadership.
Learn more: Contact us via email for further information
Prevention of Retained Surgical Items
NCPS collaborated with the VA Office of Patient Care Services to draft the Prevention of Retained Surgical Items Directive. The directive was pilot-tested at six VA facilities. It
focuses on wound exploration, counting items, and radiography, as well as the basic decision-making process to follow when a count is wrong.
Read the Prevention of Retained Surgical Items directive
Emergency Airway Management
NCPS also developed a directive to improve emergency airway management outside the operating room, in collaboration with VA Patient Care Services and field clinical representatives. VA policy now requires airway management techniques that address both equipment and practitioner requirements in airway management skills.
Read the Emergency Airway Management directive
Patient Safety Improvement Corps
In 2003, NCPS partnered with the Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) to launch a national Patient Safety Improvement Corps. NCPS formulated, managed and implemented a multifaceted training program for state health officials and their selected hospital partners. Since the program was launched, more than 300 health care professionals from 210 organizations have been trained.
Learn more: Patient Safety Improvement Corps Information from AHRQ
NCPS Pharmacists
Our pharmacists support VA Medical Center compliance with Joint Commission National Patient Safety Goals, to include accurate and complete reconciliation of patient’s medications across the continuum of care. We are also working reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
The Daily Plan
This initiative enhances patient safety by involving patients in their care: A single document is provided to them that outlines what can be expected on a specific day of hospitalization.
A facility can customize the document and include a number of items relevant to care:
- Diagnostic tests
- Medications
- Nutrition
- Appointments
- Allergies
It received a positive response from patients and staff during pilot tests at five facilities.
Patient Safety Assessment Tool
This assessment tool allows patient safety managers to complete a detailed assessment of the status of their facility’s program. The questions relate directly to the Joint Commission’s requirements.
Learn more: Patient Safety Assessment Tool
Patient Safety Initiative (PSI)
The Patient Safety Initiative was established to stimulate creative approaches to complex patient safety issues, and many successful projects have been funded in the first two years of the program.
- Twenty-six proposals funded in fiscal year 2006.
- Eighteen funded in fiscal year 2007.
VA patient safety professionals have used PSI as an opportunity to develop projects with a demonstrable impact on their patient safety programs; projects with well-defined measures and strong rationales.
Learn more: Read details about the funded proposals in the May/June 2007 and Sept./Oct. issues of Topics in Patient Safety®: Topics in Patient Safety
Patient Safety Design Challenge
The voluntary Challenge provides patient safety managers an opportunity to create a positive impact on design standards VHA-wide. Any VA facility can choose to participate.
Two categories are offered:
- Architecture and design of medical care and treatment spaces.
- Equipment layout, design and procurement (such as code of medication carts).
Four teams were recognized for taking a creative approach to design during a VA National Patient Safety Managers Conference, March 2007.
Information on the 2008 Challenge is available to VA employees on the NCPS Intranet site.
Product Recall Office
Pulling an unsafe product off the shelf and returning it to a supplier is one important way to safeguard the life or health of a patient.
Located within NCPS, the VHA’s Product Recall Office is tasked to manage recalls of all medical devices and products initiated by manufactures or the FDA that are applicable to VHA.
Recalls include not only those issued by the FDA, but can come from other external sources, such as ECRI Institute Alerts or manufacturer fieldnotifications.
Others may originate or are discovered within VHA, such as through the NCPS Patient Safety Information System, a confidential database that includes more than 14,750 root cause analysis reports and 427,900 safety reports.
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National Center for Patient Safety