Test-retest reliability of the VA National Center for Patient Safety culture questionnaire

RATIONALE, AIMS AND OBJECTIVES

Patient safety culture may have a significant influence on safety processes and outcomes. Therefore, it is important to have valid tools to measure patient safety culture in order to identify potential levers for cultural change that could improve patient safety. The 65-item Department of Veterans Affairs Patient Safety Culture Survey (VA PSCS) consists of 14 dimensions and is administered biannually to VA employees. Test-retest reliability of the VA PSCS has not been established.

METHODS

We conducted repeated administrations of the VA PSCS among 28 VA employees. We measured intraclass correlation coefficients for each item and dimension.

RESULTS

Test-retest intraclass correlation coefficient values were 0.7 or greater for 13 out of 14 dimensions of the VA PSCS. Employees had difficulty reliably reporting how others feel about patient safety.

CONCLUSIONS

In general, the VA PSCS survey showed adequate test-retest reliability. Items asking what others think or feel showed lower reliability. Further work is needed to better understand the relationship between safety culture, safety processes and safety outcomes.

Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement

The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking. The most common root cause was risk identification issues. Recommended actions were standardized risk assessment policies, patient education, and the adoption of fire stop valves. Patients with a history of smoking who are on HOT should be considered for fire stop valves and offered consistent counseling and follow-up using a combination of harm reduction and shared decision-making techniques. Standardization of risk identification and documentation is recommended.

Suicide attempts and completions in Veterans Affairs nursing home care units and long-term care facilities: a review of root-cause analysis reports

OBJECTIVE

Suicide was the 10th leading cause of death for Americans in 2010. The suicide rate is highest among men who are aged 75 and older. The prevalence of suicidal behavior in nursing homes and long-term care (LTC) facilities was estimated to be 1%. This study describes the systemic vulnerabilities found after suicidal behavior in LTC facilities as well as steps to decrease or mitigate the risk.

METHOD

This is a retrospective review of root-cause analysis (RCA) reports of suicide attempts and completions between 1 January 2000 and 31 December 2013 in the Veterans Health Administration LTC and nursing home care units. The RCA reports of suicide attempts and completions were coded for patient demographics, method of attempt or completion, root causes, and actions developed to address the root cause.

RESULTS

Thirty-five RCA reports were identified. The average age was 65 years, 11 had a previous suicide attempt, and the primary mental health diagnoses were depression, posttraumatic stress disorder, and schizophrenia. The primary methods of self-harm were cutting with a sharp object, overdose, and strangulation.

CONCLUSIONS

It is recommended that all staff members are aware of the signs and risk factors for depression and suicide in this population and should systematically assess and treat mental disorders. In addition, LTC facilities should have a standard protocol for evaluating the environment for suicide hazards and use interdisciplinary teams to promote good communication about risk factors identified among patients. Finally, staff should go beyond staff education and policy to make clinical changes at the bedside. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Wrong-side thoracentesis: lessons learned from root cause analysis

IMPORTANCE

Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences.

OBJECTIVES

To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with their occurrence.

DESIGN, SETTING, AND PARTICIPANTS

We searched the National Center for Patient Safety database for wrong-side thoracenteses performed in ambulatory clinics and hospital units other than the operating room reported from January 1, 2004, through December 31, 2011.

MAIN OUTCOMES AND MEASURES

Data extracted included patient factors, clinical features, team structure and function, adherence to bottom-line patient safety measures, complications, and outcomes.

RESULTS

Fourteen cases of wrong-side thoracenteses are identified. Contributing factors included failure to perform a time-out (n=12), missing indication of laterality on the patient's consent form (n=10), absence of a site mark on the patient's skin within the sterile field (n=12), and absent verification of medical images (n=7). Complications included pneumothoraces (n=4), hemorrhage (n=3), and death directly attributable to the wrong-side thoracentesis (n=2). Teamwork and communication failure, unawareness of existing policy, and a deficit in training and education were the most common root causes of wrong-side thoracentesis.

CONCLUSIONS AND RELEVANCE

Prevention of wrong-site procedures and accompanying patient harm outside the operating room requires adherence to the Universal Protocol and time-outs, effective teamwork, training and education, mentoring, and patient assessment for early detection of complications. The time-outs provide protected time and place for error detection and recovery.

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration

BACKGROUND

Preventable adverse events are more likely to occur among older patients because of the clinical complexity of their care. The Veterans Health Administration (VHA) National Center for Patient Safety (NCPS) stores data about serious adverse events when a root cause analysis (RCA) has been performed. A primary objective of this study was to describe the types of adverse events occurring among older patients (age > or = 65 years) in Department of Veterans Affairs (VA) hospitals. Secondary objectives were to determine the underlying reasons for the occurrence of these events and report on effective action plans that have been implemented in VA hospitals.

METHODS

In a retrospective, cross-sectional review, RCA reports were reviewed and outcomes reported using descriptive statistics for all VA hospitals that conducted an RCA for a serious geriatric adverse event from January 2010 to January 2011 that resulted in sustained injury or death.

RESULTS

The search produced 325 RCA reports on VA patients (age > or = 65 years). Falls (34.8%), delays in diagnosis and/or treatment (11.7%), unexpected death (9.9%), and medication errors (9.0%) were the most commonly reported adverse events among older VA patients. Communication was the most common underlying reason for these events, representing 43.9% of reported root causes. Approximately 40% of implemented action plans were judged by local staff to be effective.

CONCLUSION

The RCA process identified falls and communication as important themes in serious adverse events. Concrete actions, such as process standardization and changes to communication, were reported by teams to yield some improvement. However, fewer than half of the action plans were reported to be effective. Further research is needed to guide development and implementation of effective action plans.

Using a virtual breakthrough series collaborative to reduce postoperative respiratory failure in 16 Veterans Health Administration hospitals

BACKGROUND

The Institute for Healthcare Improvement (IHI) Virtual Breakthrough Series (VBTS) process was used in an eight-month (June 2011-January 2012) quality improvement (QI) project to improve care related to reducing postoperative respiratory failure. The VBTS collaborative drew on Patient Safety Indicator 11: Postoperative Respiratory Failure Rate to guide changes in care at the bedside.

METHODS

Sixteen Veterans Health Administration hospitals, each representing a regional Veterans Integrated Service Network, participated in the QI project. During the prework phase (initial two months), hospitals formed multidisciplinary teams, selected measures related to their goals, and collected baseline data. The six-month action phase included group conference calls in which the faculty presented clinical background on the topic, discussed evidence-based processes of care, and/or presented content regarding reducing postoperative respiratory failure. During a final, six-month continuous improvement and spread phase, teams were to continue implementing changes as part of their usual processes.

RESULTS

The six most commonly reported interventions to reduce postoperative respiratory failure focused on improving incentive spirometer use, documenting implementation of targeted interventions, oral care, standardized orders, early ambulation, and provider education. A few teams reported reduced ICU readmissions for respiratory failure.

CONCLUSIONS

The VBTS collaborative helped teams implement process changes to help reduce postoperative respiratory complications. Teams reported initial success at implementing site-specific improvements using real-time data. The VBTS model shows promise for knowledge sharing and efficient multifacility improvement efforts, although long-term sustainability and testing in these and other settings need to be examined.

Suicide attempts and completions on medical-surgical and intensive care units

Studies of inpatient suicide attempts and completions on medical-surgical and intensive care units are rare, and there are no large studies in the United States. We reviewed 50 cases, including 45 suicide attempts and 5 completed suicides, that occurred on medical surgical or intensive care units in the Veterans Health Administration between December 1, 1999 and December 31, 2012. The method, location, and the root causes of the events were categorized. The most common methods included cutting with a sharp object, followed by overdose and hanging. Root causes included problems with communication of risk, need for staff education in suicide assessment, and the need for better treatment for depressed and suicidal patients on medical units. Based on these results, we made our recommendations for managing suicidal patients on medical-surgical and intensive care units, including improved education for staff, standardized communication about suicide risk, and clear management protocols for suicidal patients.

The effect of simulation-based crew resource management training on measurable teamwork and communication among interprofessional teams caring for postoperative patients

BACKGROUND

Many adverse events in health care are caused by teamwork and communication breakdown. This study was conducted to investigate the effect of a point-of-care simulation-based team training curriculum on measurable teamwork and communication skills in staff caring for postoperative patients.

METHODS

Twelve facilities involving 334 perioperative surgical staff underwent simulation-based training. Pretest and posttest self-report data included the Self-Efficacy of Teamwork Competencies Scale. Observational data were captured with the Clinical Teamwork Scale.

RESULTS

Teamwork scores (measured on a five-point Likert scale) improved for all eight survey questions by an average of 18% (3.7 to 4.4, p < .05). The observed communication rating (scale of 1 to 10) increased by 16% (5.6 to 6.4, p < .05).

CONCLUSION

Simulation-based team training for staff caring for perioperative patients is associated with measurable improvements in teamwork and communication.

Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards

INTRODUCTION

One thousand five hundred suicides take place on inpatient psychiatry units in the United States each year, over 70% by hanging. Understanding the methods and the environmental components of inpatient suicide may help to reduce its incidence.

METHODS

All Root Cause Analysis reports of suicide or suicide attempts in inpatient mental health units in Veterans Affairs (VA) hospitals between December 1999 and December 2011 were reviewed. We coded the method of suicide, anchor point and lanyard for cases of hanging, and implement for cutting, and brought together all other reports of inpatient hazards from VA staff for review.

RESULTS

There were 243 reports of suicide attempts and completions: 43.6% (106) were hanging, 22.6% (55) were cutting, 15.6% (38) were strangulation, and 7.8% (19) were overdoses. Doors accounted for 52.2% of the anchor points used for the 22 deaths by hanging; sheets or bedding accounted for 58.5% of the lanyards. In addition, 23.1% of patients used razor blades for cutting.

CONCLUSIONS

The most common method of suicide attempts and completions on inpatient mental health units is hanging. It is recommended that common lanyards and anchor points be removed from the environment of care. We provide more information about such hazards and introduce a decision tree to help healthcare providers to determine which hazards to remove.

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients

Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005-12. The most common contributing factors noted in the reports included coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of short-term follow-up. Other contributing factors were team-level decision-making problems resulting from miscommunication of urgency between providers and providers' lack of awareness of or knowledge about a patient's situation; and communication failures among providers, patients, and other health care team members. Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination.

Sharing lessons learned to prevent incorrect surgery

The purpose of this report is to discuss surgical adverse event lessons learned and to recommend action. Examples of incorrect surgical adverse events managed in the Veterans Health Administration (VHA) patient safety system and results of a survey regarding the impact of the surgery lessons learned process are provided. The VHA implemented a process for sharing deidentified stories of surgical lessons learned. The cases are in-operating room selected examples from lessons learned from October 1, 2009, to June 30, 2011. Examples selected illustrate helpful human factors principles. To learn more about the awareness and impact of the lessons learned, we conducted a survey with Chiefs of Surgery in the VHA. The types of examples of adverse events include wrong eye implants, incorrect nerve blocks, and wrong site excisions of lesions. These are accompanied by human factors recommendations and change concepts such as designing the system to prevent mistakes, using differentiation, minimizing handoffs, and standardizing how information is communicated. The survey response rate was 76 per cent (88 of 132). Of those who had seen the surgical lessons learned (76% [67 of 88]), the majority (87%) reported they were valuable and 85% that they changed or reinforced patient safety behaviors in their facility as a result of surgical lessons learned. Simply having a policy will not ensure patient safety. When reviewing adverse events, human factors must be considered as a cause for error and for the failure to follow policy without assigning blame. VHA surgeons reported that the surgery lessons learned were valuable and impacted practice.

Sharing Lessons Learned to Prevent Incorrect Surgery

The purpose of this report is to discuss surgical adverse event lessons learned and to recommend action. Examples of incorrect surgical adverse events managed in the Veterans Health Administration (VHA) patient safety system and results of a survey regarding the impact of the surgery lessons learned process are provided. The VHA implemented a process for sharing deidentified stories of surgical lessons learned. The cases are in-operating room selected examples from lessons learned from October 1, 2009, to June 30, 2011. Examples selected illustrate helpful human factors principles. To learn more about the awareness and impact of the lessons learned, we conducted a survey with Chiefs of Surgery in the VHA. The types of examples of adverse events include wrong eye implants, incorrect nerve blocks, and wrong site excisions of lesions. These are accompanied by human factors recommendations and change concepts such as designing the system to prevent mistakes, using differentiation, minimizing handoffs, and standardizing how information is communicated. The survey response rate was 76 per cent (88 of 132). Of those who had seen the surgical lessons learned (76% [67 of 88]), the majority (87%) reported they were valuable and 85% that they changed or reinforced patient safety behaviors in their facility as a result of surgical lessons learned. Simply having a policy will not ensure patient safety. When reviewing adverse events, human factors must be considered as a cause for error and for the failure to follow policy without assigning blame. VHA surgeons reported that the surgery lessons learned were valuable and impacted practice.

Examination of the effectiveness of the Mental Health Environment of Care Checklist in reducing suicide on inpatient mental health units

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.

Using root cause analysis to reduce falls with injury in community settings

BACKGROUND

Falls are a common occurrence for older adults living in the community that may lead to physical injury and psychological harm. The US Department of Veterans Affairs National Center for Patient Safety (NCPS) database contains root cause analysis (RCA) reviews that identify falls resulting in injury in the community and subsequent action plans that may be helpful to prevent future falls.

METHODS

A search of the NCPS-database identified RCA reviews where the patient (community-dwelling and long term care elders) fell in the community resulting in moderate to severe injury. Falls occurred in the home, community living center, outpatient clinic, recreational outing, outdoors, or in a vehicle. Thirty-six RCAs from October 2001 through August 2010 were included. Cases were coded on the basis of location of the fall, primary activity of the patient before/during the fall, root causes, action items, outcome measures, and effectiveness of each action.

RESULTS

Sixty-seven root causes resulting in 59 actions were identified from the RCA reports. Falls most frequently occurred in the patient's home (41.7%). The most common activities the individual was engaged in during a fill included getting up from the bed or chair/wheelchair (22.2%), walking (22.2%), and transportation in a wheelchair van (14.8%). Although many actions yielded improved outcomes, the only action that was significantly associated with improvement was changes made to the environment (p = .028). setting activity

CONCLUSIONS

The and surrounding fallsthat occur in the that occur in the community and that result in moderate to serious injury were identified along with the events' root causes. The extremely limited number of reports suggests that there may be missed opportunities to conduct an RCA for adverse events that occur among community-dwelling and long term care elders.

Using root cause analysis to reduce falls with injury in the psychiatric unit

OBJECTIVE

The objective was to identify how falls on psychiatric units occur, the underlying root causes and effective action plans to reduce falls and injuries.

METHODS

A search of the Veterans Health Administration National Center for Patient Safety database was conducted to identify root cause analysis (RCA) reviews where a fall was sustained by a patient on a psychiatric unit. Seventy-five RCAs from January 2000 to March 2010 were included.

RESULTS

One hundred and thirty-eight actions were identified from the RCA reports. The most common activities the individual was engaged in during a fall included getting up from a bed, chair or wheelchair (21.3%); walking/running (10.7%); bathroom related (9.9%) or behavior related (9.9%). The most common root causes were environmental hazards (11.2%), poor communication of fall risk (8.9%), lack of suitable equipment (8.9%) and need for improvement of the current system for falls assessment (8.9%). Staff education (19.9%), development of tools to improve falls documentation (17.0%) and providing falls prevention equipment (14.2%) were the most frequent actions taken.

CONCLUSIONS

The results describe the location, activity and root causes surrounding falls that occur in psychiatric units resulting in injury, and provide some suggestions on how to implement a successful action plan.

Association between implementation of a medical team training program and surgical morbidity

OBJECTIVE

To determine whether there is an association between the Veterans Health Administration Medical Team Training (MTT) program and surgical morbidity.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective health services study was conducted with a contemporaneous control group. Outcome data were obtained from the Veterans Health Administration Surgical Quality Improvement Program. The analysis included aggregated measures representing 119,383 sampled procedures from 74 Veterans Health Administration facilities that provide care to veterans.

MAIN OUTCOME MEASURES

The primary outcome measure was the rate of change in annual surgical morbidity rate 1 year after facilities enrolled in the MTT program as compared with 1 year before and compared with the non-MTT program sites.

RESULTS

Facilities in the MTT program (n = 42) had a significant decrease of 17% in observed annual surgical morbidity rate (rate ratio, 0.83; 95% CI, 0.79-0.88; P = .01). Facilities not trained (n = 32) had an insignificant decrease of 6% in observed morbidity (rate ratio, 0.94; 95% CI, 0.86-1.05; P = .11). After adjusting for surgical risk, we found a decrease of 15% in morbidity rate for facilities in the MTT program and a decrease of 10% for those not yet in the program. The risk-adjusted annual surgical morbidity rate declined in both groups, and the decline was 20% steeper in the MTT program group (P = .001) after propensity-score matching. The steeper decline in annual surgical morbidity rates was also observed in specific morbidity outcomes, such as surgical infection.

CONCLUSION

The Veterans Health Administration MTT program is associated with decreased surgical morbidity.

Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program

There are differences between nurse and physician perceptions of teamwork. The purpose of this study was to determine whether these differences would be reduced with medical team training (MTT). The Safety Attitudes Questionnaire was administered to nurses and physicians working in the operating rooms of 101 consecutive hospitals before and at the completion of an MTT program. Responses to the 6 teamwork climate items on the Safety Attitudes Questionnaire were analyzed using nonparametric testing. At baseline, physicians had more favorable perceptions on teamwork climate items than nurses. Physicians demonstrated improvement on all 6 teamwork climate items. Nurses demonstrated improvement in perceptions on all teamwork climate items except "Nurse input is well received." Physicians still had a more favorable perception than nurses on all 6 teamwork climate items at follow-up. Despite an improvement in perceptions by physicians and nurses, baseline nurse-physician differences persisted at completion of the Veterans Health Administration MTT Program.

Changing perceptions of safety climate in the operating room with the Veterans Health Administration medical team training program

Perceptions of organizational commitment to safety differ between the operating rooms in high- and medium-complexity facilities of the Veterans Health Administration (VHA). The purpose of this study was to see whether medical team training (MTT) reduced this difference. The Safety Attitudes Questionnaire was administered before and at the completion of a MTT program. The study population consisted of respondents working in the operating room. Responses to the 7 safety climate items were analyzed using nonparametric tests. Before MTT, respondents working at medium-complexity facilities had more favorable perceptions of knowledge of proper channels and encouragement by colleagues to report safety concerns than respondents who work at high-complexity facilities. At completion, there was no difference in perceptions between respondents working at high- and medium-complexity facilities for these items. The VHA MTT program improved perceptions at both high- and medium-complexity facilities and eliminated differences present at baseline.

Systemic vulnerabilities to suicide among veterans from the Iraq and Afghanistan Conflicts: review of case reports from a National Veterans Affairs Database

While suicide among recently returned veterans is of great concern, it is a relatively rare occurrence within individual hospitals and clinics. Root cause analysis (RCA) generates a detailed case report that can be used to identify system-based vulnerabilities following an adverse event. Review of a national database of RCA reports may identify common vulnerabilities and assist in the development of more robust prevention strategies. Our objective was to identify and compare common themes among reports of suicide among veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) in the Veterans Affairs system. Common themes among root causes of suicide as identified in RCA reports were collected and compared as the primary outcome--systematic vulnerabilities. Actions recommended within the reports were coded as the secondary outcome--prevention strategies. Fifty-one RCA reports of OIF/OEF suicides were identified by our search. Coding generated 16 common categories among 132 root causes, and 13 categories among 108 recommended actions. Assessment of suicidal risk, coordination of care, timely access to care, and communication among providers were the most common root causes. Actions identified by RCA teams to reduce suicide included improving referral processes, staff education in suicide assessment, and follow-up with suicidal veterans. Review of multiple RCA reports can identify organizational vulnerabilities detected at the local level that may be applicable system wide. Attention to improving suicide assessment, coordination of care, and timely access may have the largest impact on reducing suicide among OIF/OEF veterans.