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PSRS Program Background


1998  
  Patient Safety Redesigns Included in VHA Performance Measurement System
  • Provided concrete targets and mechanisms to focus leadership efforts.
VA National Center for Patient Safety (NCPS) Established
  • Created to lead and integrate the patient safety effort for the entire VA.
  • Employs state-of-the-art human factors and safety system approaches.
  • Develops and nurtures a culture of safety throughout the VA.
VHA Expert Advisory Panel on Patient Safety System Design
  • Provided recommendations on elements for reporting systems leading to nationwide improvements.
  • Comprehensive, non-punitive analytic approach for close calls and actual adverse events defined.
Patient Safety Improvement Awards Program Started
  • Mobilizes and recognizes innovations in patient safety from all levels of the organization.
1999  
  Patient Safety Centers of Inquiry Established
  • Research groups (4) charged to develop practical solutions to critical patient safety challenges.
National Implementation of Bar Code Medication Administration (BCMA)
  • Multi-year development at one medical center resulted in cutting medication errors by two-thirds.
  • National implementation is now in progress throughout entire VA medical system.
Pilot of Comprehensive Adverse Event and Close Call Analysis Program
  • Extensive hands-on training to truly understand a human factors and safety systems approach to adverse event and close call analysis.
  • Computer assisted tool to aid implementation of comprehensive event analysis.
  • Captures critical elements needed to ensure a thorough and effective job.
  • Results in preventive actions that are superior to the status quo.
2000  
  Initiation of Patient Safety Reporting System (PSRS)
  • In May 2000 VA and NASA signed an agreement that has NASA operating the external and voluntary de-identified reporting system.
  • National in scope; complementary to mandatory reporting efforts.
  • Modeled after NASA's successful, longstanding Aviation Safety Reporting System (ASRS).
Roll-Out of Comprehensive Adverse Event and Close Call Analysis Program Completed
  • As of August 2000, program is deployed throughout all VA medical centers.