Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers.

INTRODUCTION: Adverse events in urologic procedures are poorly studied. This study analyzes the Veterans Health Administration (VHA) Root Cause Analysis (RCA) data for patient safety adverse events during urologic procedures performed in a VHA operating room (OR). MATERIALS AND METHODS: The VHA National Center for Patient Safety RCA database was queried for fiscal years 2015-2019 using urologic terms including vasectomy, prostatectomy, nephrectomy, cystectomy, cystoscopy, lithotripsy, ureteroscopy, urethral, TURBT, etc. RCAs for events outside a VHA OR were excluded. Cases were categorized based on type of event. RESULTS: Sixty-eight RCAs were identified for 319,713 urologic procedures. The most common pattern identified was equipment or instrument issue, including broken scopes or smoking light cords, with 22 cases. Eighteen RCAs involved a sentinel event, including 12 retained surgical items (RSI) (surgical sponge, retained guidewire) and 6 wrong site surgeries (WSS) (incorrect laterality, wrong procedure) representing a serious safety event rate of 1 in 17,762 procedures. In addition, 8 RCAs pertained to medical or anesthesia events (incorrect dosing, postoperative myocardial infarction), 7 to pathology errors (missing or mislabeled specimen), 4 to incorrect patient information or consent, and 4 to surgical complications (hemorrhage, duodenal injury). In 2 cases there was inappropriate work up. One case caused a delay in treatment, one case had an incorrect count, and one case identified lack of credentialing. CONCLUSIONS: RCAs of patient safety adverse events occurring during urologic OR procedures highlight the need for targeted quality improvement projects to prevent WSS events, prevent RSI events, and maintain properly functioning equipment.

Implementing Evidence-Based Pressure Injury Prevention Interventions: Veterans Health Administration Quality Improvement Collaborative.

BACKGROUND: Pressure injury prevention is a persistent concern in nursing. The Veterans Health Administration implemented a creative approach with successful outcomes across the United States. PROBLEM: Pressure injury prevention is a measure of nursing quality of care and a high priority in the Veterans Health Administration. METHODS: A 12-month Virtual Breakthrough Series Collaborative utilizing coaching and group calls was conducted to assist long-term and acute care teams with preventing pressure injuries. INTERVENTIONS: Interventions from the Veterans Health Administration Skin Bundle were implemented, including pressure-relieving surfaces, novel turning techniques, specialized dressings, and emollients to prevent skin breakdown. RESULTS: The aggregated pressure injury rate for all teams decreased from Prework to the Action phase from 1.0 to 0.8 per 1000 bed days of care (P = .01). The aggregated pressure injury rates for long-term care units decreased from Prework to Continuous Improvement from 0.8 to 0.4 per 1000 bed days of care (P = .021). CONCLUSION: The Virtual Breakthrough Series helped reduce pressure injuries.

Genome Editing and Human Reproduction: The Therapeutic Fallacy and the "Most Unusual Case".

In the current agon between those promoting and opposing the development of human reproductive applications of genome editing techniques, the bone of contention is often whether the prospective reproductive technologies answer an "unmet medical need." Proponents often point to highly unusual cases of inherited genetic conditions as exhibiting that need. This essay argues that we ought to admit that the opponents are correct: human reproductive genome editing cannot be justified on medical grounds. Taking a deliberately provocative line, the essay suggests how inscribing such practices within a conventional model of biomedical research fails to take proper account of the interrelated interests in play, including those of the wider society and its future members. It also obscures important questions about how the public significance and value of human genome editing are produced through the dynamic encounter between science, technology, and social morality. This has certain discomfiting implications that will require both courage and humility to confront and-finally, perhaps-to embrace.

Recommendations for Fall-Related Injury Prevention: A 1-Year Review of Fall-Related Root Cause Analyses in the Veterans Health Administration.

BACKGROUND: Injurious falls continue to challenge health care. Causes of serious falls from the largest health care system in the United States can direct future prevention efforts. PURPOSE: This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events. METHODS: We categorized root cause analysis (RCA) reports and coded injury type, fall type, location, and root causes. We describe interventions during the fall and provide resources for future prevention. RESULTS: There were 154 reported fall RCAs during this time. Most (83%, n = 128) resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116). CONCLUSIONS: Patients who fell were not wearing hip or head protection. Most falls were unwitnessed, and none were on 1:1 observation. Such interventions may help prevent future injurious falls.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units?

BACKGROUND: Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting. METHODS: The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient. These safety events were then matched to incidents that were reported to the VHA Adverse Event Reporting System (AERS), which includes all reported adverse events, close calls, and root cause analyses that occur within the VHA health system. RESULTS: Overall, 37.4% (95% confidence interval [CI] = 33.5%-41.5%) of safety events detected in the medical record were reported to the AERS. Among the patient safety events identified, the most commonly reported to the AERS were patient falls (52.3%), assaults (46.2%), and elopements (42.3%). Reporting rates increased when the patient safety event resulted in harm to the patient (48.2%; CI = 41.6%-55.0%). CONCLUSION: The majority of patient safety events that occur on VHA inpatient psychiatric units do not get reported to the VHA's Adverse Event Reporting System. These findings suggest that self-reporting is not a reliable method of tracking patient safety events. Future efforts should target the barriers to inpatient psychiatric reporting and develop mechanisms to overcome these barriers.

How to do a Virtual Breakthrough Series Collaborative.

Despite widespread use of the breakthrough series (BTS) collaborative in healthcare, there is limited literature on how to operationalize the method in healthcare settings. A recent modification to the model is the virtual breakthrough series (VBTS), in which all work is done remotely via telephone and web-based platforms. With virtual methods gaining popularity, this manuscript presents guidance on methods to conduct a virtual breakthrough series collaborative to assist clinical teams in implementing evidence-based practices. Manuscript describes planning activities and implementation steps for individuals interested in conducting a VBTS collaborative. Topics presented include planning/preparation activities (e.g., developing a planning committee and change package of the evidence-based interventions), estimated resources required (i.e., personnel, percent effort), activities to prepare participants for the project (e.g., orientation calls), specific actions during the virtual collaborative, and evaluation approaches. The manuscript also presents examples from our work and templates for end users. This paper is a first attempt to describe the infrastructure and processes of a VBTS collaborative and offer reproducible methods currently employed in the U.S. Veterans Health Administration.

Factors contributing to cancer-related suicide: A study of root-cause analysis reports.

OBJECTIVE: Vast efforts are directed toward curing or prolonging the life of patients with cancer. However, less attention is given to mental health aspects of cancer care, and there is elevated incidence of death by suicide in this population. Evaluating Root Cause Analyses (RCAs) of cancer-related suicides may further our understanding of system-level factors that may contribute to suicide in patients with cancer and highlight strategies to mitigate this risk. METHODS: We searched the Veterans Health Administration National Center for Patient Safety RCA database for cancer-related suicides between 2002 and 2017 to evaluate the context of the suicides and identify root causes and suggested actions. These variables were coded by consensus and evaluated using descriptive statistics. RESULTS: We identified 64 RCA reports involving cancer-related suicide; 100% were males of older age. Many suicides occurred during treatment with palliative intent (44%, N = 28). Depression (59%, N = 38), medical comorbidities (59%, N = 38), and pain (47%, N = 30) were common suicide risk factors identified. Most suicides occurred within 7 days of a medical visit (67%, N = 43), especially within the first 24 hours (41%, N = 26). Root causes included a need to improve recognition of triggers for assessment and interdisciplinary communication. CONCLUSION: This analysis uncovers opportunities to mitigate risk of death by suicide among patients with cancer. Suggested actions include use of comprehensive cancer centers and development of a distress checklist using information from the National Comprehensive Cancer Network Guidelines. Further studies should assess additional factors that may increase the risk of other adverse mental health outcomes in this population.

Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned.

BACKGROUND: Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions. METHODS: RCA reports from VHA hospitals from May 30, 2012, to May 1, 2015, were reviewed for root causes, severity of patient outcomes, and actions. These elements were coded by consensus and analyzed using descriptive statistics. RESULTS: During the study period, 3228 RCAs were submitted, of which 292 involved an anesthesia provider. Thirty-six of these were specific to anesthesia care. We reviewed these 36 RCA reports of adverse events specific to anesthesia care. Types of event included medication errors (28%, 10), regional blocks (14%, 5), airway management (14%, 5), skin integrity or position (11%, 4), other (11%, 4), consent issues (8%, 3), equipment (8%, 3), and intravenous access and anesthesia awareness (3%, 1 each). Of the 36 anesthesia events reported, 5 (14%) were identified as being catastrophic, 10 (28%) major, 12 (34%) moderate, and 9 (26%) minor. The majority of root causes identified a need for improved standardization of processes. CONCLUSIONS: This analysis points to the need for systemwide implementation of human factors engineering-based approaches to work toward further eliminating anesthesia-related adverse events. Such actions include standardization of processes, forcing functions, separating storage of look-alike sound-alike medications, limiting stock of high-risk medication strengths, bar coding medications, use of cognitive aids such as checklists, and high-fidelity simulation.

Preventing Falls and Fall-Related Injuries in State Veterans Homes: Virtual Breakthrough Series Collaborative.

This article reports on improved processes and outcomes from a virtual breakthrough series quality improvement collaborative to reduce preventable falls and fall-related injuries in 23 State Veterans Homes. Participating teams implemented 24 interventions (process changes); the most common was the postfall huddle. Teams reduced falls and fall-related injuries. This project highlights the importance of leadership support, interdisciplinary team involvement, and collaboration as essential components of fall prevention work.

Impact of The Daily Plan on Length of Stay and Readmission.

The Veterans Health Administration implemented The Daily Plan (TDP) to improve patient safety. We compared length of stay and readmission between intervention and control units. Length of stay decreased for both groups. Readmission rates increased for controls (21.3%-25.0%, P = .02) and barely changed for TDP units (21.7%-22.5%, P = .37). Although there were no efficiency improvements, TDP's ultimate goal was safety. Not all patient safety actions improve efficiency; nonetheless, their value continues.

Mortality in hepatitis C patients who achieve a sustained viral response compared to the general population.

BACKGROUND & AIMS: The number of people living with previous hepatitis C infection that have attained a sustained viral response (SVR) is expected to grow rapidly. So far, the prognosis of this group relative to the general population is unclear. METHODS: Individuals attaining SVR in Scotland in 1996-2011 were identified using a national database. Through record-linkage, we obtained cause-specific mortality data complete to Dec 2013. We calculated standardised mortality ratios (SMRs) to compare the frequency of mortality in SVR patients to the general population. In a parallel analysis, we used Cox regression to identify modifiable patient characteristics associated with post-SVR mortality. RESULTS: We identified 1824 patients, followed on average for 5.2years after SVR. In total, 78 deaths were observed. Overall, all-cause mortality was 1.9 times more frequent for SVR patients than the general population (SMR: 1.86; 95% confidence interval (CI): 1.49-2.32). Significant cause-specific elevations were seen for death due to primary liver cancer (SMR: 23.50; 95% CI: 12.23-45.16), and death due to drug-related causes (SMR: 6.58, 95% CI: 4.15-10.45). Together these two causes accounted for 66% of the total excess death observed. All of the modifiable characteristics associated with increased mortality were markers either of heavy alcohol use or injecting drug use. Individuals without these behavioural markers (32.8% of cohort) experienced equivalent survival to the general population (SMR: 0.70; 95% CI: 0.41-1.18) CONCLUSIONS: Mortality in Scottish SVR patients is higher overall than the general population. The excess was driven by death from drug-related causes and liver cancer. Health risk behaviours emerged as important modifiable determinants of mortality in this population. LAY SUMMARY: Patients cured of hepatitis C through treatment had a higher mortality rate overall than the general population. Most of the surplus mortality was due to drug-related causes and death from liver cancer. A history of heavy alcohol and injecting drug use were associated with a higher mortality risk.

Broad Anti-Hepatitis C Virus (HCV) Antibody Responses Are Associated with Improved Clinical Disease Parameters in Chronic HCV Infection.

UNLABELLED: During hepatitis C virus (HCV) infection, broadly neutralizing antibody (bNAb) responses targeting E1E2 envelope glycoproteins are generated in many individuals. It is unclear if these antibodies play a protective or a pathogenic role during chronic infection. In this study, we investigated whether bNAb responses in individuals with chronic infection were associated with differences in clinical presentation. Patient-derived purified serum IgG was used to assess the breadth of HCV E1E2 binding and the neutralization activity of HCV pseudoparticles. The binding and neutralization activity results for two panels bearing viral envelope proteins representing either an intergenotype or an intragenotype 1 group were compared. We found that the HCV load was negatively associated with strong cross-genotypic E1E2 binding (P= 0.03). Overall, we observed only a modest correlation between total E1E2 binding and neutralization ability. The breadth of intergenotype neutralization did not correlate with any clinical parameters; however, analysis of individuals with genotype 1 (gt1) HCV infection (n= 20), using an intragenotype pseudoparticle panel, found a strong association between neutralization breadth and reduced liver fibrosis (P= 0.006). A broad bNAb response in our cohort with chronic infection was associated with a single nucleotide polymorphism (SNP) in theHLA-DQB1 gene (P= 0.038), as previously reported in a cohort with acute disease. Furthermore, the bNAbs in these individuals targeted more than one region of E2-neutralizing epitopes, as assessed through cross-competition of patient bNAbs with well-characterized E2 antibodies. We conclude that the bNAb responses in patients with chronic gt1 infection are associated with lower rates of fibrosis and host genetics may play a role in the ability to raise such responses. IMPORTANCE: Globally, there are 130 million to 150 million people with chronic HCV infection. Typically, the disease is progressive and is a major cause of severe liver cirrhosis and hepatocellular carcinoma. While it is known that neutralizing antibodies have a role in spontaneous clearance during acute infection, little is known about their role in chronic infection. In the present work, we investigated the antibody response in a cohort of chronically infected individuals and found that a broadly neutralizing antibody response is protective and is associated with reduced levels of liver fibrosis and cirrhosis. We also found an association between SNPs in class II HLA genes and the presence of a broadly neutralizing response, indicating that antigen presentation may be important for the production of HCV-neutralizing antibodies.

Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports.

There is a high risk for death by suicide after discharge from an inpatient mental health unit. To better understand system and organizational factors associated with postdischarge suicide, we reviewed root cause analysis reports of suicide within 7 days of discharge from across all Veterans Health Administration inpatient mental health units between 2002 and 2015. There were 141 reports of suicide within 7 days of discharge, and a large proportion (43.3%, n = 61) followed an unplanned discharge. Root causes fell into three major themes including challenges for clinicians and patients after the established process of care, awareness and communication of suicide risk, and flaws in the established process of care. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to postdischarge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges.

Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration.

BACKGROUND: ICUs' provision of complex care for critically ill patients results in an environment with a high potential for adverse events. A study was conducted to characterize adverse events in Veterans Health Administration (VHA) ICUs that underwent root cause analysis (RCA) and to identify the root causes and their recommended actions. METHODS: This retrospective observational study of RCA reports concerned events that occurred in VHA ICUs or as a result of ICU processes from January 1, 2013, through December 31, 2014. The type of event, root causes, and recommended actions were measured. RESULTS: Some 70 eligible RCAs were identified in 47 of the 120 facilities with an ICU in the VHA system. Delays in care (30.0%) and medication errors (28.6%) were the most common types of events. There were 152 root causes and 277 recommended actions. Root causes often involved rules, policies, and procedure processes (28.3%), equipment/supply issues (15.8%), and knowledge deficits/education (15.1%). Common actions recommended were policy, procedure, and process actions (34.4%) and training/education actions (31.4%). Of the actions implemented, 84.4% had a reported effectiveness of "much better" or "better." CONCLUSION: ICU adverse events often had several root causes, with protocols and process-of-care issues as root causes regardless of event type. Actions often included standardization of processes and training/education. Several recommendations can be made that may improve patient safety in the ICU, such as standardization of care process, implementation of team training programs, and simulation-based training.

Preventing Pressure Ulcers in the Veterans Health Administration Using a Virtual Breakthrough Series Collaborative.

The Veterans Health Administration implemented a Virtual Breakthrough Series to prevent pressure ulcers. The pressure ulcer rate decreased from 1.2 to 0.9 per 1000 bed days of care (P = .017). The most common interventions were education (N = 26; 68%), improved documentation (N = 23; 61%), and the use of equipment and supplies (N = 21; 55%). In summary, this project helped improve pressure ulcer rates in the Veterans Health Administration and presents a promising model for implementing a virtual model for improvement.

Factors associated with spontaneous clearance of chronic hepatitis C virus infection.

BACKGROUND & AIMS: Spontaneous clearance of chronic hepatitis C virus (HCV) infection (CHC) is rare. We conducted a retrospective case-control study to identify rates and factors associated with spontaneous clearance of CHC. METHODS: We defined cases as individuals who spontaneously resolved CHC, and controls as individuals who remained chronically infected. We used data obtained on HCV testing between 1994 and 2013 in the West of Scotland to infer case/control status. Specifically, untreated patients with ⩾2 sequential samples positive for HCV RNA ⩾6months apart followed by ⩾1 negative test, and those with ⩾2 positive samples ⩾6months apart with no subsequent negative samples were identified. Control patients were randomly selected from the second group (4/patient of interest). Case notes were reviewed and patient characteristics obtained. RESULTS: 25,113 samples were positive for HCV RNA, relating to 10,318 patients. 50 cases of late spontaneous clearance were identified, contributing 241 person-years follow-up. 2,518 untreated, chronically infected controls were identified, contributing 13,766 person-years follow-up, from whom 200 controls were randomly selected. The incidence rate of spontaneous clearance was 0.36/100 person-years follow-up, occurring after a median 50months' infection. Spontaneous clearance was positively associated with female gender, younger age at infection, lower HCV RNA load and co-infection with hepatitis B virus. It was negatively associated with current intravenous drug use. CONCLUSIONS: Spontaneous clearance of CHC occurs infrequently but is associated with identifiable host and viral factors. More frequent HCV RNA monitoring may be appropriate in selected patient groups. LAY SUMMARY: Clearance of hepatitis C virus infection without treatment occurs rarely once chronic infection has been established. We interrogated a large Scottish patient cohort and found that it was more common in females, patients infected at a younger age or with lower levels of HCV in the blood, and patients co-infected with hepatitis B virus. Patients who injected drugs were less likely to spontaneously clear chronic infection.

Liver Fibrosis, but No Other Histologic Features, Is Associated With Long-term Outcomes of Patients With Nonalcoholic Fatty Liver Disease.

BACKGROUND & AIMS: Histologic analysis of liver biopsy specimens allows for grading and staging of nonalcoholic fatty liver disease (NAFLD). We performed a longitudinal study to investigate the long-term prognostic relevance of histologic features for patients with NAFLD. METHODS: We performed a retrospective analysis of 619 patients diagnosed with NAFLD from 1975 through 2005 at medical centers in the United States, Europe, and Thailand. Patients underwent laboratory and biopsy analyses, and were examined every 3-12 months after their diagnosis. Outcomes analyzed were overall mortality, liver transplantation, and liver-related events. Cumulative outcomes were compared by log-rank analysis. Cox proportional-hazards regression was used to estimate adjusted hazard ratios (HRs). Time at risk was determined from the date of liver biopsy to the date of outcome or last follow-up examination. RESULTS: Over a median follow-up period of 12.6 years (range, 0.3-35.1 y), 193 of the patients (33.2%) died or underwent liver transplantation. Features of liver biopsies significantly associated with death or liver transplantation included fibrosis stage 1 (HR, 1.88; 95% confidence interval [CI], 1.28-2.77), stage 2 (HR, 2.89; 95% CI, 1.93-4.33), stage 3 (HR, 3.76; 95% CI, 2.40-5.89), and stage 4 (HR, 10.9; 95% CI, 6.06-19.62) compared with stage 0, as well as age (HR, 1.07; 95% CI, 1.05-1.08), diabetes (HR, 1.61; 95% CI, 1.13-2.30), current smoking (HR, 2.62; 95% CI, 1.67-4.10), and statin use (HR, 0.32; 95% CI, 0.14-0.70). Twenty-six patients (4.2%) developed liver-related events; fibrosis stage 3 (HR, 14.2; 95% CI, 3.38-59.68) and stage 4 (HR, 51.5; 95% CI, 9.87-269.2) compared with stage 0, were associated significantly with the events. Patients with fibrosis, regardless of steatohepatitis or NAFLD activity score, had shorter survival times than patients without fibrosis. CONCLUSIONS: In a longitudinal study of patients with NAFLD, fibrosis stage, but no other histologic features of steatohepatitis, were associated independently with long-term overall mortality, liver transplantation, and liver-related events.

Toward a more complete understanding of the association between a hepatitis C sustained viral response and cause-specific outcomes.

UNLABELLED: Sustained viral response (SVR) is the optimal outcome of hepatitis C virus (HCV) therapy, yet more detailed data are required to confirm its clinical value. Individuals receiving treatment in 1996-2011 were identified using the Scottish HCV clinical database. We sourced data on 10 clinical events: liver, nonliver, and all-cause mortality; first hospitalisation for severe liver morbidity (SLM); cardiovascular disease (CVD); respiratory disorders; neoplasms; alcohol-intoxication; drug intoxication; and violence-related injury (note: the latter three events were selected a priori to gauge ongoing chaotic lifestyle behaviours). We determined the association between SVR attainment and each outcome event, in terms of the relative hazard reduction and absolute risk reduction (ARR). We tested for an interaction between SVR and liver disease severity (mild vs. nonmild), defining mild disease as an aspartate aminotransferase-to-platelet ratio index (APRI) <0.7. Our cohort comprised 3,385 patients (mean age: 41.6 years), followed-up for a median 5.3 years (interquartile range: 3.3-8.2). SVR was associated with a reduced risk of liver mortality (adjusted hazard ratio [AHR]: 0.24; P < 0.001), nonliver mortality (AHR, 0.68; P = 0.026), all-cause mortality (AHR, 0.49; P < 0.001), SLM (AHR, 0.21; P < 0.001), CVD (AHR, 0.70; P = 0.001), alcohol intoxication (AHR, 0.52; P = 0.003), and violence-related injury (AHR, 0.51; P = 0.002). After 7.5 years, SVR was associated with significant ARRs for liver mortality, all-cause mortality, SLM, and CVD (each 3.0%-4.7%). However, we detected a strong interaction, in that ARRs were considerably higher for individuals with nonmild disease than for individuals with mild disease. CONCLUSIONS: The conclusions are 3-fold: (1) Overall, SVR is associated with reduced hazard for a range of hepatic and nonhepatic events; (2) an association between SVR and behavioral events is consistent with SVR patients leading healthier lives; and (3) the short-term value of SVR is greatest for those with nonmild disease.

Suicide attempts and completions in Veterans Affairs nursing home care units and long-term care facilities: a review of root-cause analysis reports.

OBJECTIVE: Suicide was the 10th leading cause of death for Americans in 2010. The suicide rate is highest among men who are aged 75 and older. The prevalence of suicidal behavior in nursing homes and long-term care (LTC) facilities was estimated to be 1%. This study describes the systemic vulnerabilities found after suicidal behavior in LTC facilities as well as steps to decrease or mitigate the risk. METHOD: This is a retrospective review of root-cause analysis (RCA) reports of suicide attempts and completions between 1 January 2000 and 31 December 2013 in the Veterans Health Administration LTC and nursing home care units. The RCA reports of suicide attempts and completions were coded for patient demographics, method of attempt or completion, root causes, and actions developed to address the root cause. RESULTS: Thirty-five RCA reports were identified. The average age was 65 years, 11 had a previous suicide attempt, and the primary mental health diagnoses were depression, posttraumatic stress disorder, and schizophrenia. The primary methods of self-harm were cutting with a sharp object, overdose, and strangulation. CONCLUSIONS: It is recommended that all staff members are aware of the signs and risk factors for depression and suicide in this population and should systematically assess and treat mental disorders. In addition, LTC facilities should have a standard protocol for evaluating the environment for suicide hazards and use interdisciplinary teams to promote good communication about risk factors identified among patients. Finally, staff should go beyond staff education and policy to make clinical changes at the bedside. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Virtual Breakthrough Series, Part 2: Improving Fall Prevention Practices in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help prevent falls and fall-related injuries. This project enabled teams to expand program infrastructure, redesign improvement strategies, and enhance program evaluation. METHODS: A VBTS collaborative involves prework, action, and continuous improvement. Actions included educational calls, monthly reports, coaching, and feedback. Evaluation included assessment of interventions, team capacity and infrastructure changes, and rates of falls and fall-related major injuries. RESULTS: Fifty-nine teams completed the project. The majority submitted monthly reports. The average number of interventions per team was 6.66 (range, 1-12; mode = 6). The most frequently implemented changes were staff education; post-fall huddles; data tracking; and classifying falls, handoff communication, and intentional rounding. On a program questionnaire aggregated average summary scores improved from 136.54 (baseline) to 58.26 (follow-up; range, 0-189; p < 0.0001). The mean aggregated fall-related major injury rate for participants decreased from 6.8 to 4.8 per 100,000 bed-days of care (p = 0.02), or 5 major injuries avoided per month. No statistically significant changes occurred for nonparticipants. The mean aggregated fall rate did not change significantly from baseline to follow-up for participants (p = 0.42) or nonparticipants (p = 0.21). CONCLUSION: Teams submitted reports and implemented changes resulting in decreased major injuries related to falls for participating units. Teams also made changes in their fall prevention programs such as classifying how they analyze falls and implementing injury reduction strategies. The approaches used show promise for reducing fall-related harm for inpatients, as well as assisting teams in implementing changes.