|
VA NCPS Milestones 1998 - 2008
January 2008
NCPS Product Recall Office Designated
- Tasked to manage recalls of all medical devices and products initiated by manufactures or the FDA that are applicable to VHA.
October 2007
- Six Patient Safety Centers of Inquiry funded.
July 2007
Patient Safety Fellowship Program Launched
- Co-sponsored by the VA Office of Academic Affiliations; eleven fellows selected for the initial program.
June 2007
Patient Safety Initiative Funded 18 Proposals Developed in Fiscal Year 2007
March 2007
Patient Safety Design Challenge
- Four teams were recognized for taking a creative approach to design during the VA National Patient Safety Managers Conference.
September 2006
Patient Safety Improvement Corps
- NCPS completed patient safety training for Improvement Corps participants from all 50 states and the District of Columbia, a three-year project.
August 2006
Automated Patient Safety Assessment Tool Launched
Patient Safety Initiative funded 26 Proposals Developed in Fiscal Year 2006
March 2006
Patient Safety Initiative Announced
- The goal of PSI is to stimulate creative approaches to complex patient safety issues among VA patient safety officers and managers.
April 2006
Prevention of Retained Surgical Items Directive Issued
December 2005
NCPS staff Member Received a Cheers Award From the Institute for Safe Medication Practices
- The award honors those who have set a standard of excellence in the prevention of medication errors and adverse drug events.
September 2005
Patient Safety Design Challenge Announced
- The voluntary program allows patient safety managers to create a positive impact on design standards VA-wide.
June 2005
Airway Management Initiative Launched
Joint Commission Resources Published “Using Human Factors Engineering to Improve Patient Safety”
- NCPS staff member, editor.
May 2005
Second Patient Safety Culture Survey Conducted
April 2005
BETA Test for Automated Patient Safety Assessment Tool Conducted
NCPS Director Received a Patient Safety Award
- James P. Bagian, PE, MD.
- Presented by the Centers for Disease Control and Prevention, in partnership with the Institute for Quality in Laboratory Medicine.
- Acknowledged for “pioneering” work in patient safety and “contributions to improvements in healthcare.”
March 2005
Falls Data Collection Project Launched
February 2005
NCPS Updated the American Heart Association “Emergency Cardiovascular Care Handbook for Code Carts”
Hand Hygiene Directive Issued; Dedicated Web Page Offered
November 2004
NCPS Program Manager Selected as a Distinguished Alumnus by Wayne State University’s Pharmacy Alumni Association Affiliate Board of Directors
- Recognized for significant and sustained contributions to her field.
September 2004
First Medical Team Training Session Conducted VA Medical Center Houston, Texas
Falls Toolkit Launched
- Multimedia kit aimed at reducing falls among elderly patients.
June 2004
Six Sigma/3M Hand Hygiene Project Completed
April 2004
NCPS Program Manager Joe DeRosier Earned Bronze Telly Award for Outstanding Achievement in Video Production, Developing the “Safe Use of Oxygen” Training Video
February 2004
NCPS Conducted Patient Safety Workshops for Senior Leadership
December 2003
VHA Guidelines on Hand Hygiene Requirements Issued
October 2003
NCPS Director Honored with Career Achievement
- James P. Bagian, PE, MD.
- The Partnership for Public Service honored the NCPS Director with a Service to America Medal.
September 2003
The National Patient Safety Improvement Corps Launched
- VHA/NCPS embarked upon a three-year interagency agreement with the Department of Health and Human Services’ Agency for Healthcare Research and Quality to launch a national “Patient Safety Improvement Corps.”
- NCPS tasked to formulate, manage and implement a multifaceted training program for state health officials and their selected hospital partners.
Medical Team Training Pilot-Tested
- Grounded in two decades of aviation safety and human factors engineering studies, the initiative will be used to evaluate the effectiveness of team training in high-risk environments, such as the operating room.
April 2003
Patient Safety Curriculum Pilot Begun
- Pilot testing of faculty development workshops for physician teachers began; actively solicited academic affiliate buy-in and partnership opportunities.
February 2003
Patient Safety Assessment Tool Launched
- The tool allows patient safety managers to complete a detailed assessment of the status of their facility’s program and was pilot tested and evaluated by four networks.
- Began training of VA facility directors, patient safety officers, and patient safety managers in its use.
January 2003
Ensuring Correct Surgery Directive Implemented
- The directive offers a simple, straight forward five-step procedure to avoid adverse surgical events.
- A collection of cognitive aids were created to support providers and patients (e.g., video, brochure, poster, Inter- and Intranet Web sites).
August 2002
U.S. Medicine Honored Director with Frank Brown Berry Prize
- James P. Bagian, PE, MD.
- Awarded the prize for conceiving and establishing a comprehensive patient safety system that emphasizes prevention of adverse medical events, rather than punishment of providers, through the reporting and analysis of adverse events and close calls.
July 2002
NCPS staff member launched Patient Safety Curriculum Initiative
- The initiative continues development of a patient safety curriculum for medical students, residents, and other healthcare professionals derived from six years of work with residents at Michigan State University and nursing students at Western Michigan University.
- Several physicians and patient safety personnel from VA medical centers and affiliated universities volunteered to assist with the development and testing of the patient safety curriculum pilot.
June 2002
Patient Safety Information Systems Director Earned a Becton Dickinson Career Achievement Award
- Given to “encourage and support further contributions by healthcare professionals in the improvement of medical devices, instruments, or systems. The intent is to identify, recognize, and encourage outstanding achievement(s) by a promising healthcare professional.”
April 2002
Tool Kit for Improving Patient Safety Made Available
- Created in partnership with the American Hospital Association
- The toolkit helps hospitals prioritize and evaluate aspects of care delivery that may be at high-risk for causing patient harm or have been associated with an adverse event or close call.
February 2002
NCPS Awarded the John M. Eisenberg Patient Safety Award for System Innovation
- Recognized for “developing and implementing a systems approach to error reduction within the VHA’s 163 healthcare facilities.”
- Presented for projects or initiatives involving successful system changes or interventions that make the environment of care safer.
November 2001
NCPS selected for 2001 Innovations in American Government Award
- One of five winners for this national honor; the only federal program selected from more than 1,200 applicants.
- NCPS was cited for preventing and reducing adverse medical events by addressing systemic vulnerabilities.
VA/Quality Interagency Coordination Task Force (QuIC) Summit on Effective Practices to Improve Patient Safety Convened
- Organized by NCPS to improve patient safety.
- Presented information for immediate use by patient safety managers.
- Attended by approximately 350 professionals (VA and non-VA).
August 2001
Healthcare Failure Mode and Effect AnalysisSM Launched
- Included training program and cognitive aids.
July 2001
NCPS Director Honored by the American Medical Association
- James P. Bagian, PE, MD, received the AMA’s Dr. Nathan Davis Award.
- The award, named for the founding father of the AMA, recognizes elected and career officials in federal, state, or municipal service whose outstanding contributions have promoted the art and science of medicine and the betterment of public health.
March 2001
Patient Safety Reporting System (PSRS) Pilot-Tested
- First pilot test with Veterans Integrated Service Network (VISN) 22.
- Second pilot test follows in December 2001 with VISN 16.
January 2001
Roll-Out of New Root Cause Analysis Software (The Patient Safety Information System, Nicknamed “SPOT”)
- SPOT further automates the VA patient safety reporting analysis process and corrective action measures.
- Features include enhanced analysis capabilities at the facility level; secure electronic submission of RCAs from facilities to NCPS; tools to follow up, track, and document corrective actions and outcome measurements; and tools to develop automated flow charts.
August 2000
Comprehensive Adverse Event and Close Call Analysis Program Launched
- Spanning 10 months, NCPS conducted training on safety improvement methods to more than 700 personnel who had been selected to lead patient safety programs at VA facilities.
May 2000
VA Contracted with NASA to Create Patient Safety Reporting System (PSRS)
- PSRS launched as an external, voluntary, and confidential program.
- Developed to complement an internal comprehensive adverse event and close call analysis program.
- Acts as a “safety valve” to help ensure that otherwise unknowable vulnerabilities are identified.
First Patient Safety Cultural Survey Conducted
April 2000
Roll-Out of Adverse Event and Close Call Analysis Program
- After pilot testing with VISNs 8 and 22, NCPS begins roll-out of the program throughout VA medical system.
- VA and healthcare professionals from other public and private sector healthcare entities, nationally and internationally, begin attending NCPS-sponsored training on a regular basis.
November 1999
Pilot Testing of Adverse Event and Close Call Analysis Program
- First pilot test conducted at VISN 8.
- Second pilot test follows in February 2000 at VISN 22.
February 1999
NCPS is Established
- James P. Bagian, PE, MD, begins work as the first NCPS Director.
Fall 1998
VA National Center for Patient Safety is Announced
Return to top of page
|
National Center for Patient Safety