STATEMENT OF
AUDREY L. NELSON, PH.D., RN, FAAN
DIRECTOR, VISN 8 PATIENT SAFETY CENTER OF INQUIRY
JAMES A. HALEY VETERANS HOSPITAL
TAMPA, FL

VA PATIENT SAFETY CENTER OF INQUIRY

BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS, SUBCOMMITTEE ON HEALTH
AND THE
COMMITTEE ON COMMERCE, SUBCOMMITTEES ON HEALTH & ENVIRONMENT AND
OVERSIGHT AND INVESTIGATIONS

February 9, 2000

Mr. Chairmen and Members of the Committees,

I am pleased to appear before you to discuss an example of a VA innovation to support patient safety, the establishment of Patient Safety Centers of Inquiry. Our center is one of the four centers that were funded for three years starting in March 1999. The VISN 8 Patient Safety Center of Inquiry focuses on Safe Mobility for Frail Elderly and Persons with Disabilities. Specifically, our center’s focus is on efforts to prevent patient falls and promote safe wheelchair mobility. Falls are a critical problem in health care, accounting for 25% to 84% of all adverse events in hospitals.

The mission of our center is to support clinicians in providing safe patient care by designing and testing clinical innovations, technological solutions, and patient safety improvement systems. Our research efforts will target two patient populations with compromised mobility: frail elderly and persons with disabilities.

We have identified two primary goals: (1) to improve functional status and quality of life for frail elderly and persons with disabilities by addressing mobility enhancement and safety issues, and (2) to build a "culture of safety" to support clinicians in providing safe patient care and safe working environments. To address these goals, our research efforts have focused in four key areas:

• Develop and Test Clinical Innovations Related to Safe Mobility

• Design Technological Solutions Related to Safe Mobility

• Redesign Patient Safety Systems

• Facilitate Innovation Diffusion

Our center includes staff with expertise in a variety of disciplines, including: architecture, computer science, epidemiology, ergonomics, industrial design, health economics, industrial engineering, interior design, law, mechanical engineering, medical equipment manufacturing, medicine, nursing, social sciences, technology brokerage, and quality/risk management. Many of our project teams include consumers.

We are actively collaborating with partners in industry and government, as well as public and private sectors. In addition to consumers, key partners include: ARJO®, the Joint Commission on Accreditation of Health Care Organizations (JCAHO), Food and Drug Administration (FDA), Museum of Science and Industry, Paralyzed Veterans of America (PVA), University of South Florida, VA Healthcare Analysis & Information Group, and VHA Office of Quality & Performance. In the future, we plan to partner with the Agency for Healthcare Research & Quality (AHRQ), National Institutes of Health (NIH), and the National Aeronautics and Space Administration (NASA).

We have a number of projects underway to address safe mobility. A few of these projects are outlined below:

• Establish Gait and Balance Clinics to prevent falls in high risk veterans
• Evaluate Tai Chi as a strategy for Fall Prevention
• Evaluate a Tele-monitoring program to Prevent Falls for Veterans with Parkinson’s Disease
• Develop a Resource Guide to Identify Alternatives to Bed Rails for Frail Elderly
• Develop a Resource Guide for Safe Patient Movement
• Develop Clinical Pathways to prevent falls
• Design an Evidence-Based Program for Fall Risk Assessment & Prevention
• Convene an Expert Panel to set Research Agenda for Patient Falls
• Evaluate Fall Risk Assessment Tools
• Develop Clinical Practice Guidelines to Preserve Upper Extremity Function in Wheel Chair Users
• Pilot test the National Patient Safety Handbook
• Identify barriers to reporting patient safety incidents/near misses
• Describe the epidemiology of falls in a variety of health care settings
• Develop a report on the direct and indirect costs of patient falls in VA
• Conduct a biomechanical assessment of safe wheelchair transfers to preserve upper extremity function in persons with spinal cord injuries
• Conduct a biomechanical assessment of the gait of individuals who repeatedly fall
• Redesign patient lifting equipment to prevent patient and caregiver injuries
• Participate on the AHRQ sponsored Expert Panel to set the Research Agenda for Health Care Environments
• Establish a Consensus Validation Conference for "Technology to Support Safe Patient Care" (hope to partner with VA’s Rehabilitation Research & Development Service, NIH, AHRQ, NIOSH)
• Establish a web-based VA Safety Information Center
• Design of a safe patient care room of the future, evaluate its effectiveness in the VA healthcare environment, and display this prototype at the Museum of Science and Industry

Conclusion:

We believe that VA deployment of resources and expertise will allow us to address the significant safety challenges related to safe mobility for frail elderly and persons with disabilities. Our efforts will impact persons living in the community as well as persons in acute, long-term care, or assisted living facilities. We are working closely with consumers, as well as partners in industry, government agencies, and the private sector to provide practical solutions to patient safety problems. We will work with VA’s National Center for Patient Safety to disseminate these innovations throughout VHA, the larger health care arena, and to the general public. We appreciate your support of these efforts, and would be delighted to share our progress in the future.

This concludes my statement. My colleagues and I would be happy to answer any questions.