Vha national patient safety improvement handbook

Developing and Testing PASS In order to best translate existing practices into the electronic tool, the development team will work with teams of clinical and patient safety staff in the field to introduce, explore and evaluate the new features of PASS. The development team plans to facilitate pilot sessions during facility level HFMEAs to gain valuable insight from end users.

A phased development and implementation plan will create opportunities for discussion, analysis and mid-course improvement. Finally, in a third release, PASS will enable VA service chiefs to develop standard health care process templates that are either specific to one service line or span multiple service lines. This will create an opportunity for service chiefs to lead large scale, multidisciplinary, multi-facility HFMEAs leveraging the insight of staff from numerous sites and service areas.

The Future of VA Proactive Risk Assessments Reliance on reactive, piecemeal improvements to small elements of a complex system ultimately cannot help identify or remediate the things that could go wrong. Alternatively — when we study how processes intertwine, thoughtfully determine which vulnerabilities we can control, and challenge ourselves to acknowledge our weaknesses — we empower each other to overcome those weaknesses and proactively address broken systems before they cause harm.

References 1. VHA Handbook Veterans Crisis Line: Press 1. March 27, January 4, Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. March 15, Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about.

October 21, September 9, Health Care Providers. Health Care Executives and Administrators. Root Cause Analysis. Back To Top. Patient Safety Primers Topics Glossary. Improvement Resources Innovations Toolkits. Connect With Us. Sign up for Email Updates To sign up for updates or to access your subscriber preferences, please enter your email address below. PSNet Log in. Username or e-mail address. Remember me. Forgot password? Log in. Don't have account? Our objective for TIPS is to provide useful and timely topics concerning patient safety.

Many facilities are working to find ways to reduce the number of falls as well as the severity of the falls that do occur. In an effort to help facilities, we created the Falls Toolkit. We have developed a number or tools, training, and software to facilitate patient safety efforts at VA facilities around the nation, such as our cognitive aids.