United States Department of Veterans Affairs

National Center for Patient Safety

TIPS | Patient Safety Improvement Handbook | Cognitive Aids | Other Publications

Topics In Patient Safety (TIPS)

TIPS is our bimonthly newsletter that offers readers a wide range of topics on patient safety and suggestions on actions that can improve patient safety. Our objective for TIPS is to provide useful and timely topics concerning patient safety.

The latest issue:

November/December 2008 covers disruptive behavior, soft doors, a three-hospital cooperative effort, and The Daily Plan.(PDF)

Previous issues can be found in the TIPS Archive.

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NCPS Patient Safety Improvement Handbook
NCPS Patient Safety Improvement Handbook - the handbook developed at the National Center for Patient Safety Return to top of page


Cognitive Aids
Ordering the NCPS Cognitive Aids
  • Triage Cards™ - presents questions RCA teams need to know the answer to when completing RCAs and describes how to use the 5 Rules of Causation when developing causation statements.
  • Fall Prevention and Management - tips and suggestions on how to initiate and implement fall prevention interventions and strategies.
  • Escape and Elopement Management - tips and suggestions on interventions that may be used to prevent patients from escaping and eloping.
  • The Healthcare Failure Mode Effect Analysis™ Process - provides tips, hints, and directions on how to complete a proactive risk assessment using the NCPS developed model.
  • Root Cause Analysis Tools - provides tips, hints and directions on how to complete an RCA using the NCPS developed analysis process including use of Event Flow and Cause and Effect diagramming.
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Other Publications
  • The NCPS 2006 Profile offers readers a detailed understanding of the full range of our programs and initiatives. It includes a number of charts that help illustrate the breadth of the program and specific examples of safety challenges we have addressed since the organization was founded in 1999
  • Using Health Care Failure Mode and Effect Analysis™: The VA National Center for Patient Safety's Prospective Risk Analysis System © (PDF)  (HTML) by Joseph DeRosier, PE, CSP; Erik Stalhandske, MPP, MHSA; James P. Bagian, MD, PE; Tina Nudell, MS. The Joint Commission Journal on Quality Improvement Volume 27 Number 5:248-267, 2002. Posted with permission.

  • VISN 8 Patient Safety Center of Inquiry Fall Incident Report including Morse Fall Scale.
    The Fall Incident Report form was developed in VISN 8, as a joint effort of the VISN 8 Quality Management/Risk Management, under the leadership of Joanne Elkins, MSN, RN, CPHQ, and Lula Williams, MN, RN, CPHQ, together with the VISN 8 Evidence-based Fall Prevention Program, under the leadership of Pat Quigley, ARNP-C, PhD, and Andrea M. Spehar, MS, DVM, MPH. The development of new reporting forms was initiated by the VISN 8 Patient Safety Improvement Board, consisting of the VISN 8 QMs and RMs and members of the VISN 8 Patient Safety Center.

  • Developing a Culture of Safety in the Veterans Health Administration published in Effective Clinical Practice
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