VA’s Commitment to Safe Care

Surgeons work on a patient


A Culture of Safety

Not too long ago, if somebody did something wrong in a hospital that caused harm to a patient, the “name and blame” response kicked in.

Hospitals would conduct an investigation of the events that caused harm to a patient. The emphasis of the investigation was on individual correction or discipline. Find out who did something wrong and punish them.

Today at VA, the goal is to find out what happened, why it happened, and how to prevent it from happening again. It’s a culture of safety and it’s based on understanding and prevention. Human error is not punished.

One of VA’s top priorities is reducing and preventing inadvertent harm to VA patients.

That is the sole purpose of VA’s National Center for Patient Safety, which has the important task of developing and nurturing a culture of safety throughout the Veteran’s Health Administration.

To get that job done there are patient safety managers at all 153 VA medical centers and patient safety officers at 21 regional VA networks.

According to Dr. Robin Hemphill, “Our goal is simple, the reduction and prevention of inadvertent harm to our patients as a result of their care.” Dr. Hemphill is Director of the National Center for Patient Safety.

Portrait of a woman

Dr. Robin Hemphill

VA uses a multi-disciplinary team approach, known as Root Cause Analysis (RCA) to study health care-related adverse events and close calls. RCA teams investigate how well patient care systems function, focusing on “how” and “why,” not “who.”

A tool for indentifying prevention strategies

According to Dr. Hemphill, “In root cause analysis, basic and contributing causes are discovered in a process similar to diagnosis of disease, with the goal always in mind of preventing recurrence. Root cause analysis is a tool for identifying system failures and vulnerabilities and then developing prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.”

“We look at the tougher question, why did this adverse event occur?”

Reducing or eliminating harm to patients is the real key to patient safety. Efforts that focus exclusively on eliminating errors will fail. It’s impossible to eliminate all individual errors. The goal is to design systems that are “fault tolerant,” so that when an individual error occurs, it does not result in harm to a patient.

That’s why VA’s patient safety program is based on a systems approach to problem solving. The Veterans Health Administration uses methods and applies ideas from “high reliability” organizations, such as aviation and nuclear power, to target and eliminate system vulnerabilities.

Learning from Close Calls

As Beth King, R.N, puts it, “We don’t target people. We look for ways to break that link in those underlying systems-based vulnerabilities to prevent problems.” Beth is a program manager with the National Center for Patient Safety.

She adds, “One of the most important ways to do this is to learn from close calls, sometimes called “near misses,” which occur at a much higher frequency than actual adverse events. Addressing problems in this way not only results in safer systems, but it also focuses everyone’s efforts on continually identifying potential problems and fixing them.”

This doesn’t mean VA is a “blame-free” organization. The Department has a system that delineates what type of activities may result in disciplinary action and which do not. Only those events that are intentionally unsafe acts can result in the assignment of blame and punitive action.

Dr. Hemphill concludes, “We believe people come to work to do a good job, not to do a bad job. Given the right set of circumstances, any of us can make a mistake. We must force ourselves to look past the easy answer, that an adverse event was someone’s fault. We want to look at the tougher question, why did this adverse event occur?

“That’s our job at the National Center for Patient Safety, a job we do every day with one person in mind…the Veteran.”

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