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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 Veterans Administration often leads the pack. This giant healthcare machine which serves over 5. 8 million patients every year used to be thought of as the pariah of healthcare. In fact as recently as 1992 the care at VA hospitals was so substandard that Congress considered shutting down the entire system and giving ex-G.I.s vouchers for treatment at private facilities.
Today it's a very different story. The VA runs the largest integrated health-care system in the country, with more than 1,400 hospitals, clinics and nursing homes employing 14,800 doctors, 61,000 nurses and over 100,000 others to manage patients. Because of all the changes that took place including more aggressive management there was a much higher chance for errors and mistakes, however the VA was able to avoid many of the problems that plagued other healthcare systems, by starting the National Center for Patient Safety. This division is charged with the new Taking Aim at Medication Errors program.
This month our publisher, Steve Freed, caught up with Keith W. Trettin, R.Ph., MBA, Program Manager at the Veterans Health Administration's (VA) National Center for Patient Safety (NCPS) in Ann Arbor, Michigan to find out how they established the program, how it is working and if it might work in the non-government setting.
David Joffe
Editor-in-chief
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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 only adverse events, but close calls. The NCPS staff members also use the system to track and analyze the root causes of adverse events and close calls. The Patient Safety Information System, nicknamed "SPOT," provides….
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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 focused exclusively on eliminating errors will fail….
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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 indicator for prevalence of safety incidents. As I had mentioned, it can be used for identifying trends in incidents [Diabetes and Insulin Management Summary (including system vulnerabilities and suggested solutions) pdf attached]….
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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 insulin and questioned its validity. The actual dose desired by the physician was 200 units. The physician indicated the 40 units reflected the mark on a U 100 syringe to which the patient was to draw back the plunger"….
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