Summary: The Department of Veterans Affairs (VA) has undertaken several initiatives to better detect and prevent adverse events, including falls, medication errors, missing patients, and suicides. For example, VA has established systems that include bar code technology to prevent blood product and medication administration errors. VA is completing its implementation of a revised mandatory adverse event reporting and prevention process; the success of this initiative depends on VA establishing a culture in which employees feel safe to openly report actual adverse events as well as close calls. VA has used strategies suggested by the Institute of Medicine for creating a culture of safety. It should also increase its emphasis on leadership strategies by measuring its progress against the Institute strategies: patient safety, clear responsibilities and expectations, and communicating the importance of patient safety to staff. VA has not yet prepared a detailed implementation plan that identifies how and when VA's various patient safety initiatives will be implemented, how they are aligned to support improved patient safety, and what contribution each initiative can be expected to make toward the goal of improved patient safety. safety.
