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The Veterans Health Administration's Approach To Patient Safety

Last fall, the National Academy of Science's Institute of Medicine release a controversial report entitled "To Err Is Human," which claimed that between 44,000 to 98,000 die every year as a result of medical errors. To put that number in perspective, if the airline industry's fatality rate was as high, five major crashes would have to take place every day.

The leaders of the medical community greeted the report with suspicion. The report drew sweeping conclusions based on the examination of two studies. One study from 1984, the Harvard Medical Practice Study, and a review of 15,000 records from Colorado and Utah hospitals in 1992.

The scrutiny has put the issue of medical errors on the table. The government recommended the creation of a nationwide reporting system and a new federal agency, the Center for Patient Safety.

The VA Hospital system took a proactive approach and started its own safety system. When a serious error takes place at a V.A. hospital, a pannel of staff members investigates the event and recommends changes. Some solutions are high-tech. The VA has equipped nurses with handheld scanners that match the bar codes on drug vials to those on a patient's identification bracelet.

The VA has set up a Web site for patient safety known as the Virtual Learning Center. The Center has 17 patient safety lessons on everything from alternative medicine to suicide assessment. Each lessons identifies a problem within the VA's patient population, lists interventions and measures outcomes.

You may visit the Virtual Learning Center at Other items of interest to be found at the site include a list of medications with revised FDA labels, medical device recalls, the lesson of the day and a what's new section. Some of the site is still under development.

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Editor: Susan K. Boyer, RN
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