National Center for Patient Safety

Ann Arbor, Michigan, United States

National Center for Patient Safety

Ann Arbor, Michigan, United States
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OBJECTIVE: This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur. METHODS: This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database. Adverse event type, procedure, location, severity, and frequency were extracted. Spearman ρ was used to determine associations between types of adverse events and harm levels. RESULTS: We reviewed 27 cases of reported adverse events related to GI invasive procedures. Of the adverse events for which we could determine location (n = 25), 10 (40%) were in the operating room and 15 (60%) occurred in a nonoperating room. Endoscopies were associated with the least amount of harm. The most frequently reported adverse event types were human factors (22.22%, n = 6) and retained items (18.52%, n = 5). Retained item events were associated with the most harm. The most common root causes were lack of standardization in the process of care and suboptimal communication. CONCLUSIONS: Retained items after invasive procedures and human factors errors were the most common and harmful type of adverse event in this study. Efforts to reduce adverse events during GI invasive procedures include improving situational awareness of the risk of retained items, standardization of care, communication between providers, and inspection of instruments for intactness before and after procedures. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved

Ronconi J.M.,White River Junction Veterans Affairs Medical Center | Shiner B.,White River Junction Veterans Affairs Medical Center | Watts B.V.,National Center for Patient Safety
Journal of Psychiatric Practice | Year: 2014

Objective. Posttraumatic stress disorder (PTSD) is a prevalent and often disabling condition. Fortunately, effective psychological treatments for PTSD are available. However, research indicates that these treatments may be underutilized in clinical practice. One reason for this underutilization may be clinicians' unwarranted exclusion of patients from these treatments based on their understanding of exclusion criteria used in clinical trials of psychological treatments for PTSD. There is no comprehensive and up-to-date review of inclusion and exclusion criteria used in randomized clinical trials (RCTs) of psychological treatments for PTSD. Therefore, our objective was to better understand how patients were excluded from such RCTs in order to provide guidance to clinicians regarding clinical populations likely to benefit from these treatments. Methods. We conducted a comprehensive literature review of RCTs of psychological treatments for PTSD from January 1, 1980 through April 1, 2012. We categorized these clinical trials according to the types of psychotherapy discussed in the major guidelines for treatment of PTSD and reviewed all treatments that were studied in at least two RCTs (N=64 published studies with 75 intervention arms since some studies compared two or more interventions). We abstracted and tabulated information concerning exclusion criteria for each type of psychotherapy for PTSD. Results. We identified multiple RCTs of cognitive behavioral therapy (n=56), eye movement desensitization and reprocessing (n=11), and group psychotherapy (n=8) for PTSD. The most common exclusions were psychosis, substance abuse and dependence, bipolar disorder, and suicidal ideation. Clinical trials varied in how stringently these criteria were applied. It is important to note that no exclusion criterion was used in all studies and there was at least one study of each type of therapy that included patients from each of the commonly excluded groups. A paucity of evidence exists concerning the treatment of patients with PTSD and four comorbidities: alcohol and substance abuse or dependence with current use, current psychosis, current mania, and suicidal ideation with current intent. Conclusions. Psychological treatments for PTSD have been studied in broad and representative clinical populations. It appears that more liberal use of these treatments regardless of comorbidities is warranted. (Journal of Psychiatric Practice 2014;20:25-37) Copyright © 2014 Lippincott Williams & Wilkins Inc.

Watts B.V.,National Center for Patient Safety | Schnurr P.P.,National Center for PTSD | Young-Xu Y.,National Center for Patient Safety | Friedman M.J.,National Center for PTSD
Journal of Clinical Psychiatry | Year: 2013

Objective: Posttraumatic stress disorder (PTSD) is an important mental health issue in terms of the number of people affected and the morbidity and functional impairment associated with the disorder. The purpose of this study was to examine the efficacy of all treatments for PTSD. Data Sources: PubMed, MEDLINE, PILOTS, and PsycINFO databases were searched for randomized controlled clinical trials of any treatment for PTSD in adults published between January 1, 1980, and April 1, 2012, and written in the English language. The following search terms were used: post-traumatic stress disorders, posttraumatic stress disorder, PTSD, combat disorders, and stress disorders, post-traumatic. Study Selection: Articles selected were those in which all subjects were adults with a diagnosis of PTSD based on DSM criteria and a valid PTSD symptom measure was reported. Other study characteristics were systematically collected. The sample consisted of 137 treatment comparisons drawn from 112 studies. Results: Effective psychotherapies included cognitive therapy, exposure therapy, and eye movement desensitization and reprocessing (g = 1.63, 1.08, and 1.01, respectively). Effective pharmacotherapies included paroxetine, sertraline, fluoxetine, risperidone, topiramate, and venlafaxine (g = 0.74, 0.41, 0.43, 0.41, 1.20, and 0.48, respectively). For both psychotherapy and medication, studies with more women had larger effects and studies with more veterans had smaller effects. Psychotherapy studies with wait-list controls had larger effects than studies with active control comparisons. Conclusions: Our findings suggest that patients and providers have a variety of options for choosing an effective treatment for PTSD. Substantial differences in study design and study participant characteristics make identification of a single best treatment difficult. Not all medications or psychotherapies are effective. © 2013 Copyright Physicians Postgraduate Press, Inc.

Watts B.V.,National Center for Patient Safety | Young-Xu Y.,National Center for Patient Safety | Mills P.D.,National Center for Patient Safety | DeRosier J.M.,National Center for Patient Safety | And 3 more authors.
Archives of General Psychiatry | Year: 2012

Context: Suicide is one of the leading causes of death in the United States. While suicides occurring during psychiatric hospitalization represent a very small proportion of the total number of suicides, these events are highly preventable owing to the controlled nature of the environment. Many methods have been proposed, but no interventions have been tested. Objective: To evaluate the effect of identification and abatement of hazards on inpatient suicides in the Veterans Health Administration (VHA). Design, Setting, and Patients: The effect of implementation of a checklist (the Mental Health Environment of Care Checklist) and abatement process designed to remove suicide hazards from inpatient mental health units in all VHA hospitals was examined by measuring change in the rate of suicides before and after the intervention. Intervention: Implementation of the Mental Health Environment of Care Checklist. Main Outcome Measure: The number of completed suicides on inpatient mental health units in VHA hospitals. Results: Implementation of the Mental Health Environment of Care Checklist was associated with a reduction in the rate of completed inpatient suicide in VHA hospitals nationally. This reduction remained present when controlling for number of admissions (2.64 per 100 000 admissions before to 0.87 per 100 000 admissions after implementation; P < .001) and bed days of care (2.08 per 1 million bed days before to 0.79 per 1 million bed days after implementation; P < .001). Conclusions: Use of the Mental Health Environment of Care Checklist was associated with a substantial reduction in the inpatient suicide rate occurring on VHA mental health units. Use of the checklist in non-VHA hospitals may be warranted.

News Article | November 28, 2016

A new study shows a sharp decline in suicides at Veterans Affairs inpatient mental health units from 2000 to 2015, thanks to the Mental Health Environment of Care Checklist. The checklist, introduced in VA in 2007 and in use at more than 150 VA hospitals nationwide, guides staff in eliminating physical hazards on mental health inpatient units that raise the risk of patient suicide or self-harm. The study appeared online Nov. 15, 2016, in the journal Psychiatric Services. The researchers found a sustained reduction in inpatient suicides during the last seven years of the study period, with none occurring in each of the last three years. The checklist focuses on architectural and other physical-environment changes. Earlier analyses had shown that most attempted or completed suicides on inpatient units were linked to such hazards--for example, a hook or other anchor point that could be using for hanging. The study's lead author, Dr. Vince Watts, says the research produced two main findings. "First, it appears that the Mental Health Environment of Care Checklist has had a substantial and persistent reduction in inpatient suicide deaths," he says. "Second, these findings suggest that architectural and environmental changes may result in more lasting effects in contrast to other improvement strategies for reducing suicides in hospital units." Other strategies for preventing suicides in hospitals include training staff better, performing more frequent checks of patients, and implementing a non-punitive culture that rewards incident-reporting and supports its continued improvement. Watts, a psychiatrist at the White River (Vermont) VA Medical Center, and the study's other three researchers are with the VA National Center for Patient Safety, based in Ann Arbor, Michigan. The program was created in 1999 to lead formal patient-safety activities across the VA health system. One of its first actions was to institute a root cause analysis of adverse events such as inpatient suicide. Root cause analysis, used widely in industry, is a systematic approach that helps organizations identify and address the underlying causes of problems, instead of just "putting out fires" when they occur. In a review of the National Center for Patient Safety's root cause analysis database, the researchers learned of 29 completed suicides in VA mental health units from 2000 to 2015 (24 before implementation of the checklist and five after). The rate of suicide in mental health units before the program kicked off was 4.2 per 100,000 admissions. It dropped to 0.74 suicides per 100,000 admissions--an 82 percent reduction. The new study is an extension of a 2012 report led by Watts that linked the checklist to a drop in the inpatient suicide rate at VHA mental health units. Structural changes, according to Watts, reduce the burden on hospital staff to prevent suicides. "The checklist and resulting environmental changes involve hardwiring of changes into the architecture of mental health units," he says. "Thus, staff don't have to remember to do something. The unit is just designed that way." Another implication of the finding, Watts says, is that there may be other effective approaches that, like structural changes, create no added burden on staff. One such approach would be the increased use of automated technologies to help provide care for patients with mental illness. "Technologies tend to be better at performing the same task repeatedly," he says. "This could have implications in the mental care system for veterans and non-veterans." As for limitations of the research, Watts and his coauthors point out it's possible some inpatient suicides were not reported. This would affect the before-and-after comparisons. Also, the effects of the checklist were tracked for only seven years. Watts says the impact of the program could possibly drop in the coming years. "Future staff could stop using it and reverse the changes," he says. "Staff members change and forget what was done and why it is done. Then one day a patient or nurse complains that they don't have a place to hang their robe. Hospital workers try to accommodate this suggestion and put a hook on the wall. Later, that hook is used as an anchor point for a suicide attempt. We hope that won't happen, but we continue to monitor in case it does." "Our goal is to have no inpatient suicides in the VA," he adds. "Our hope is that a continued focus on this approach will result in a continued reduction in suicide."

Neily J.,National Center for Patient Safety | Mills P.D.,National Center for Patient Safety | Young-Xu Y.,National Center for Patient Safety | Carney B.T.,National Center for Patient Safety | And 7 more authors.
JAMA - Journal of the American Medical Association | Year: 2010

Context: There is insufficient information about the effectiveness of medical team training on surgical outcomes. The Veterans Health Administration (VHA) implemented a formalized medical team training program for operating room personnel on a national level. Objective: To determine whether an association existed between the VHA Medical Team Training program and surgical outcomes. Design, Setting, and Participants: A retrospective health services study with a contemporaneous control group was conducted. Outcome data were obtained from the VHA Surgical Quality Improvement Program (VASQIP) and from structured interviews in fiscal years 2006 to 2008. The analysis included 182 409 sampled procedures from 108 VHA facilities that provided care to veterans. The VHA's nationwide training program required briefings and debriefings in the operating room and included checklists as an integral part of this process. The training included 2 months of preparation, a 1-day conference, and 1 year of quarterly coaching interviews Main Outcome Measure: The rate of change in the mortality rate 1 year after facilities enrolled in the training program compared with the year before and with nontraining sites. Results: The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P=.01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P=.59). The risk-adjusted mortality rates at baseline were 17 per 1000 procedures per year for the trained facilities and 15 per 1000 procedures per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 procedures per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in the risk-adjusted surgical mortality rate was about 50% greater in the training group (RR,1.49; 95% CI, 1.10-2.07; P=.01) than in the nontraining group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program, a reduction of 0.5 deaths per 1000 procedures occurred (95% CI, 0.2-1.0; P=.001). Conclusion: Participation in the VHA Medical Team Training program was associated with lower surgical mortality. ©2010 American Medical Association. All rights reserved.

Williams L.C.,National Center for Patient Safety
Human Factors and Ergonomics In Manufacturing | Year: 2012

The illusions that occur in healthcare are inadvertent, certainly unintended, and unfortunately accepted as an aspect of practice with which clinicians have to cope. There are inadvertent illusions and unintended magic in medical devices, software, and in the healthcare environment generally. The engineer, programmer, manufacturer, or architect may not recognize the unintended magic in his or her own designs. Yet the clinician is seen as responsible when the illusion results in unexpected harm to a patient. By being unwilling to suspend disbelief in the face of illusion when it isn't clear what's real, clinicians can end the magic. It is possible to use magic and illusion to show the value of human factors engineering and ergonomics (HFE) in identifying and solving patient safety issues. HFE experts with this ability are equipped to unmask illusion and reveal magic at work in healthcare. Clinicians may see unmasking illusion as equivalent to accurate diagnosis of system ills and the first step in being able to treat system illness. In considering the state of healthcare culture, the use of simple magic tricks brings heightened awareness of tricky medical systems in need of repair and the need for tool-based problem solving native to HFE. © 2011 Wiley Periodicals, Inc.

Carney B.T.,National Center for Patient Safety | Mills P.D.,National Center for Patient Safety | Bagian J.P.,National Center for Patient Safety | Weeks W.B.,National Center for Patient Safety
Quality and Safety in Health Care | Year: 2010

Background Achieving a culture of safety is believed to be an important mechanism for improving patient safety. The Safety Attitudes Questionnaire (SAQ) measures provider perceptions of patient safety culture across six domains; higher scores denote more positive perceptions. Although professional differences on the SAQ have been explored, sex differences have not. Methods The SAQ was administered to operating room (OR) care givers at nine Department of Veterans Affairs hospitals. We determined the mean domain scores by care giver profession and sex, used analysis of variance to compare mean scores across professions, used t tests to compare mean scores between sexes and created regression models of the six patient safety domains. Results The SAQ was completed by 187 OR care givers. Older care givers were significantly more likely to report favourable perceptions of teamwork climate; surgeons were significantly more likely to report favourable perceptions of working conditions; anaesthesia providers were significantly more likely to report favourable perceptions of stress recognition but also less favourable perceptions of safety climate. Women were significantly more likely to report less favourable perceptions of job satisfaction and working conditions. Conclusion This pilot study confirms previously reported profession differences in OR care giver patient safety attitudes. We also found previously unreported sex differences. Educational efforts designed to enhance patient safety should be designed so that they address such differences.

Shanawani H.,National Center for Patient Safety
Journal of Religion and Health | Year: 2016

Conscientious objection (CO) is the refusal to perform a legal role or responsibility because of personal beliefs. In health care, conscientious objection involves practitioners not providing certain treatments to their patients, based on reasons of morality or “conscience.” The development of conscientious objection among providers is complex and challenging. While there may exist good reasons to accommodate COs of clinical providers, the exercise of rights and beliefs of the provider has an impact on a patient’s health and/ or their access to care. For this reason, it is incumbent on the provider with a CO to minimize or eliminate the impact of their CO both on the delivery of care to the patients they serve and on the medical system in which they serve patients. The increasing exercise of CO, and its impact on large segments of the population, is made more complex by the provision of government-funded health care benefits by private entities. The result is a blurring of the lines between the public, civic space, where all people and corporate entities are expected to have similar rights and responsibilities, and the private space, where personal beliefs and restrictions are expected to be more tolerated. This paper considers the following questions: (1) What are the allowances or limits of the exercise a CO against the rights of a patient to receive care within accept practice? (2) In a society where there exist “private,” personal rights and responsibilities, as well as “civil” or public/shared rights and responsibilities, what defines the boundaries of the public, civil, and private space? (3) As providers and patients face the exercise of CO, what roles, responsibilities, and rights do organizations and institutions have in this interaction? © 2016, Springer Science+Business Media New York.

Sine D.M.,National Center for Patient Safety
Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management | Year: 2011

Patient-centered care is driven in part by the ethical principle of autonomy and considers patients' cultural traditions, personal preferences, values, family situations, and lifestyles. Patient decision-making capacity, surrogate decision making with or in the absence of a patient's advance directive, and the right to refuse treatment are three patient-care issues that are central to the work done by both the risk manager and the clinical ethicist that have strong relevance to patient-centered care. This article discusses these three issues briefly and offers two challenging case studies involving patient-centered care that illustrate how a clinical ethics consultation may help to avert the escalation that can lead to a tort claim. © 2011 American Society for Healthcare Risk Management of the American Hospital Association.

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