NCPS: Taking Aim at Medication Errors, Question 1

a confidential, non-punitive reporting system that allows users to electronically document patient safety information from across the VA so that lessons learned can benefit the entire system. Since SPOT was first pilot-tested in 1999, more than16,500 RCA reports and 659,800 safety reports have been placed in the system.

Using specialized software, SPOT can be searched for trends and for a listing of specific events. Following the implementation of SPOT, a 30-fold increase in event reporting and a 1,000-fold increase in the conduct of RCAs were noted, reflecting the level of commitment to the program by VA leaders and staff members throughout the medical system. Close calls are given the same level of scrutiny as adverse events that result in harm to a patient, as they occur anywhere from 3-to-300 times more often than actual adverse events. A willingness and an avenue to report problems are essential to safe care because one can't fix what one doesn't know about. The SPOT database in part of our efforts to develop a Culture of Safety at the VA, by taking a systems approach to problem solving -- based on prevention, not punishment.

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PDF  Patient Safety Alert: Insulin U-500 Safety Enhancements (March 2009)

PDF  NCPS: Diabetes and Insulin Management Topic Summary

For more general information on preventing, catching and reporting errors, see our Safety and Error Prevention page.