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VA Digs to the Root of Adverse Events

Kate Traynor

The National Center for Patient Safety (NCPS), started three years ago by the Department of Veterans Affairs (VA), has turned to root-cause analysis for studying adverse medical events, determining their underlying causes, and finding ways to learn from and prevent errors.

"We don't use the word 'error,'" says NCPS Director James P. Bagian, M.D., who views adverse events as opportunities for learning, not punishable offenses. He says VA can learn from both adverse events and "close calls"—events that might have harmed a patient but didn't, either through good luck or someone's quick action.

VA's new internal system of root-cause analysis was introduced last year. Initial staff training at all 172 VA hospitals wrapped up this August.

Comparing the new program to VA's previous system, John W. Gosbee, M.D., the person in charge of NCPS's database, says, "We probably have at least as many adverse events reported, many more close calls than ever reported, probably better communication up and down the line when a close call or adverse event happens."

After analysis of an adverse event, the corrective action could be as simple as the double checks familiar to pharmacists.

"Pharmacists have many systematic things that have been built into their work process for years," says Gosbee, adding that routine checking is "a key part of the training of pharmacists."

But "a lot of times you're starting from square one," says Gosbee, if double checks need to be incorporated into procedures elsewhere in the hospital.

Each hospital's adverse-event database has information that can identify the people involved in the event. The VA removes identifiers before forwarding the data to other hospitals so as to avoid stigmatizing anyone or any facility.

Stripping data of identifiers will also be critical to encouraging participation in the VA's $8.2 million voluntary, external reporting system under development by the National Aeronautics and Space Administration (NASA), says Bagian. After receiving a report, NASA will delete anything that identifies people or hospitals. Only then will the data be returned to VA for analysis.

In comparing the two complementary systems, Bagian says, "the internal system gives you very detailed information and is very efficient." But the NASA system gives people the freedom "to report certain aspects they didn't manage to tell internally but they think somebody should know…So the external NASA 'de-identified' system allows you to learn those things that are [otherwise] unknowable."

In September, VA hosted a working group that addressed the terminology of adverse events. ASHP Executive Vice President Henri R. Manasse, Jr., Ph.D., Sc.D., spoke at the session.