Letter from the Editor: November Special Edition
Often when we think of cutting edge technology or modern methods of care the private sector tends to get all the attention and it seems that often government agencies only catch up years later. However, when it comes to healthcare innovations, the...
NCPS: Taking Aim at Medication Errors, Question 4
SF: Can you give an example of how the error reporting works?
KT: I have attached a NCPS Alert (in pdf format) from March 2009 on U 500 Insulin. This was the specific incident: "South West VA CMOP received an order for 40 units of U-500...
NCPS: Taking Aim at Medication Errors, Question 3
SF: What are the most common errors that occur at the VA in regards to diabetes patients and what has the VA done to prevent them from happening again?
KT: The data found within NCPS SPOT data is voluntarily reported so it is not a good...
NCPS: Taking Aim at Medication Errors, Question 2
SF: How do you minimize errors?
KT: Here is some more background to better understand the basis of our program. Neither the VA nor any other health care system can or will ever be able to "eliminate all errors." Patient safety programs...
NCPS: Taking Aim at Medication Errors, Question 1
SF: What is the VA's NCPS doing to change the medical safety culture so medical professionals will report all errors not just the ones that cause harm?
KT: We developed a confidential reporting system that allows VA caregivers to report not...
