Adverse Patient Safety Events During the COVID-19 Epidemic.

METHODS: A retrospective descriptive analysis of patient safety events related to COVID-19 was performed on data that were submitted in the Joint Patient Safety Event Reporting System and Root Cause Analysis databases to the VHA National Center for Patient Safety from March 2020 to February 2021. Events were coded for type of event, location, and cause of event. RESULTS: Delays in care and staff/patients exposed to COVID-19 were the most common types of patient safety events, followed by COVID-19-positive patients eloping, laboratory processing errors, and one wrong procedure. The most frequently cited locations where events took place were emergency departments, medical units, community living centers, and intensive care units. Confusion over procedures, care not provided because of COVID-19, and failure to identify COVID-positive patient before they exposed others to COVID were the most common causes for patient safety events. DISCUSSION: Our results are similar to other studies of patient safety during the first year of the COVID-19 pandemic. Based on these results, we recommend the following: (1) focus on patient safety culture, leadership, and governance; (2) proactively develop competency checklists, cognitive aids, and other tools for healthcare staff who are working in new or unfamiliar clinical settings; (3) augment or enhance communication efforts with patient safety huddles or briefings at all levels within a healthcare organization to proactively uncover risk and mitigate fear by explaining changes in policies and procedures; and (4) maximize the use of quality and patient safety experts who are knowledgeable in system and human factor theories as well as change management to assist in redesigning clinical workflows and processes.

Delays in Care During the COVID-19 Pandemic in the Veterans Health Administration.

OBJECTIVES: The purpose of this study was to review patient safety reports in the Veterans Health Administration (VHA) related to delays during an 11-month period that included months of the COVID-19 pandemic. DESIGN: A retrospective descriptive analysis of COVID-19 patient safety reports related to delays that were submitted in the Joint Patient Safety Event Reporting System database to the VHA National Center of Patient Safety from January 01, 2020 to November 15, 2020 was conducted. There were 897 COVID-19 patient safety events related to delays; 200 cases were randomly selected for analysis, with 148 meeting inclusion criteria. RESULTS: The results showed delays in laboratory results, level of care, treatment and interventional procedures, specific aspects of care, radiology treatment, and diagnosis. Causes for delays included poor communication between staff, problems in getting laboratory results, confusion over policy, and misunderstanding of COVID-19-specific rules. CONCLUSIONS: Healthcare delays can be reduced during a pandemic by proactively standardizing medical processes/procedures when testing for infection, improving staff to staff communication teaching the SBAR (situation, background, assessment, and recommendations) communication model, and using simulation to identify latent safety issues and educating medical personnel on new protocols related to the pandemic. Simulation can be used to test new protocols developed during the pandemic.

Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care.

INTRODUCTION: Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. MATERIALS AND METHODS: A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. RESULTS: Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. CONCLUSIONS: It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.

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.

Delays in Diagnosis, Treatment, and Surgery: Root Causes, Actions Taken, and Recommendations for Healthcare Improvement.

OBJECTIVES: Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients. The purpose of this study was to review root cause analysis (RCA) reports in the Veterans Health Administration to identify the root causes and contributing factors of delays in diagnosis, treatment, or surgery in an effort to prevent avoidable delays in future care. METHODS: The RCA reports from Veterans Health Administration hospitals from October 2016 through September 2019 were reviewed and the root causes and contributory factors were identified. These elements were coded by consensus and analyzed using descriptive statistics. RESULTS: During the 3-year study period, 206 RCAs were identified and 163 were analyzed that were specific to delays in diagnosis, treatment, and surgery. The reports identified 24 delays in diagnosis, 117 delays in treatment, and 22 delays in surgery. Delays occurred most often in outpatient settings. CONCLUSIONS: Results supported the need for standardization of care processes and procedures, improved communication between and within department personnel, and improved policies and procedures that will be followed as intended. By reviewing adverse events, root causes, and contributing factors identified by local RCA teams, strategies can be developed to reduce delays in diagnosis and treatment of patients and lead to safer care.

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration.

OBJECTIVES: Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy. METHODS: From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff. RESULTS: Of the 281 bleeding events reviewed, 188 (67%) were unwitnessed and 54 (19%) were associated with an alteration in mental status. Most deaths (n = 11; 79%) were associated with central venous catheter access. Root cause analyses reported 83 root causes, of which 33% identified physical barriers to direct observation or an equipment issue.Action plans addressed policy/procedures (30%), training/education (20%), and changes to environment/equipment (19%). Patient Safety Advisory publication was associated with a significant increase in low-harm PS reports, from 9 to 18 per year (P = 0.001). CONCLUSIONS: Bleeding events during hemodialysis treatments occur and may be fatal. Heightened vigilance is required when physical barriers obscure continuous direct observation, the patient exhibits an altered mental status, and vascular access is through a central venous catheter.Provider staff should consider a safety checklist and training on equipment operation. Patient Safety Advisory publication was associated with increased low-harm event reporting.

Suicide and Suicide Attempts on Veterans Affairs Medical Center Outpatient Clinic Areas, Common Areas, and Hospital Grounds.

OBJECTIVES: Few studies have analyzed suicide deaths and attempts occurring outside inpatient units on other hospital locations. We aimed to quantify and analyze suicide deaths and attempts occurring on Department of Veterans Affairs medical center outpatient clinic areas, common areas, and hospital grounds including parking lots to determine whether a relationship with access to mental health care exists and to elucidate potential mitigation strategies. METHODS: We conducted a retrospective review of patient safety report (n = 3,186), root cause analysis (n = 234), and issue brief (n = 2,064) national databases between January 1, 2015, and December 31, 2018, to identify occurrences of suicides and attempts. Correlation between mental health access times and hospital-specific rates of suicides and attempts was assessed. Qualitative analyses of root causes and mitigation strategies were conducted. RESULTS: Of 192 reports meeting our location criteria, 42 suicides or attempts occurred in outpatient clinic areas, 39 in common spaces, and 111 on outdoor facility areas. Forty-four reports (23%) pertained to suicides, and 148 (77%) pertained to attempts. The predominate methods were death by firearms (64%) and attempt by drug overdose (38%). We identified a weak yet significant relationship between mental health access times for established patients and rates of on-campus suicides and attempts (r = 0.279, P = 0.0013). CONCLUSIONS: Clinical changes including environmental assessments and interventions, staff training on identifying suicide risk characteristics, policy changes toward improving contraband search techniques, and medications risk assessment, as well as timely access to care may be effective mitigation strategies toward preventing suicides of this nature.

Review of Reported Adverse Events Occurring Among the Homeless Veteran Population in the Veterans Health Administration.

BACKGROUND: United States veterans face an even greater risk of homelessness and associated medical conditions, mental health conditions, and fatal and nonfatal overdose as compared with nonveterans. Beginning 2009, the Department of Veterans Affairs developed a strategy and allocated considerable resources to address veteran homelessness and the medical conditions commonly associated with this condition. OBJECTIVE: This study aimed to examine the Veterans Health Administration National Center for Patient Safety database for patient safety events in the homeless veteran population to mitigate future risk and inform policy. METHODS: This was a retrospective, descriptive quality improvement study of reported patient safety events of homeless veterans enrolled in Veterans Health Administration care between January 2012 and August 2020. A validated codebook was used to capture individual patient characteristics, location and type of event, homeless status, and root causes of the events and proposed actions for prevention. RESULTS: Suicide attempt or death, elopement, delay in care, and unintentional opioid overdose were the most common adverse events reported for this population. Root causes include issues with policies, procedures, and care processes for managing and evaluating homeless patients for the risk of suicidal or overdose behaviors and discharge, poor interdisciplinary communication, and coordination of patient care. Actions included standardization of procedures for discharge, overdose and suicide risk, staff education, and purchasing new equipment. CONCLUSIONS: Suicide and opioid overdose are the most serious reported health care-related adverse events in the unsheltered homeless veteran population. Failures to recognize homelessness status, communicate status, and coordinate available services are root causes of these events.

Trends in healthcare utilisation during COVID-19: a longitudinal study from the UK.

OBJECTIVE: The first wave of the COVID-19 pandemic had a major impact on healthcare utilisation. The aim of this retrospective review was to quantify how utilisation of non-COVID care changed during this time so as to gain insight and inform planning of future services during potential second and subsequent waves. METHODS AND ANALYSIS: A longitudinal design was used to analyse anonymous private UK health insurer datasets covering the period of January 2018 to August 2020. Taken as a measure of healthcare utilisation in the UK, incidence rates of claims broken down by service area and condition were calculated alongside overall monthly totals and costs. Pre-COVID-19 years were compared with the current year. RESULTS: Healthcare utilisation during the first wave of COVID-19 decreased by as much as 70% immediately after lockdown measures were implemented. After 2 months, the trend reversed and claims steadily began to increase, but did not reach rates seen from previous years by the end of August 2020. Assessment by service and diagnostic category showed that most areas, especially those highly reliant on in-person treatment, reflected the same pattern (ie, rapid drop followed by a steady recovery). The provision of mental health services differed from this observed trend, where utilisation increased by 20% during the first wave of COVID-19, in comparison to pre-COVID-19 years. The utilisation of maternity services and the treatment of existing cancers also stayed stable, or increased slightly, during this time. CONCLUSIONS: Healthcare utilisation in a UK-based privately insured population decreased dramatically during the first wave of the COVID-19 pandemic, being over 70% lower at its height. However, mental health services remained resilient during this time, possibly due to greater virtualisation of diagnostics and care.

Root Cause Analysis of Adverse Events Involving Opioid Overdoses in the Veterans Health Administration.

OBJECTIVE: The Veterans Health Administration (VHA) serves a population with compounding risk factors for opioid misuse, including chronic pain, substance use disorders, and mental health conditions. The objective of this study was to analyze opioid-related adverse events and root causes to inform mitigation strategies associated with opioid prescribing and administration. METHODS: The researchers conducted a retrospective analysis of root cause analysis reports of opioid overdose events between August 1, 2012, and September 30, 2019. These adverse events were investigated locally by multidisciplinary hospital teams and reported by VHA facility patient safety managers to the National Center for Patient Safety for further aggregation and analysis. Type of event, location, and root causes were categorized. RESULTS: Eighty-two adverse event reports were identified. Patients were primarily male with an average age of 61.4 years. Staff medication administration errors were the most common event type (57.3%), with most events resulting from process errors (65.9%) occurring in the health care setting (85.4%). Overall 36 events (43.9%) resulted in major or catastrophic harm. There were 172 root causes identified. The most common root causes were staff not following existing policy or lack of existing hospital policy on opioid management (18.0%); staff lacked training in areas such as managing the use or administration of opioids, correct use of opioid dispensing equipment, and recognition and proper response to an overdose (12.2%); and poor communication of opioid prescribing or administration during handoffs between clinical teams (11.6%). A lack of standardization in processes, training, and policies on opioid prescribing and screening, medication administration, equipment/pumps purchase and use, and contraband searches was a common theme throughout. CONCLUSION: Errors in prescribing and administration of opioid medication can result in significant harm. A lack of standardized opioid administration practices and training, controlled substance policies, and interdisciplinary communication were frequent factors in adverse opioid events and should be a focus for future prevention.

Delirious Mania: An Approach to Diagnosis and Treatment.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Power Failures During Surgery: A 2000-2019 Review of Reported Events in the Veterans Health Administration.

OBJECTIVES: The frequency and impact of power failure on surgical care over time in a large integrated healthcare system such as the Veterans Health Administration (VHA) is unknown. Reducing the likelihood of harm related to these rare but potential catastrophic events is imperative to ensuring patient safety and high-quality surgical care. This study provides analysis and description of reported power failures during surgery (January 2000-March 2019), in the VHA and their impact. METHODS: This quality improvement study describes patient safety adverse events related to power failure in the operating room reported by 63 VHA medical centers from the approximately 137 VHAs with a surgical program. Power failure events during surgery reported to the VHA National Center for Patient Safety are analyzed. RESULTS: The authors identify 20 root cause analyses and 135 safety reports. Most events 36.1% (n = 56) resulted from generator delay, equipment reboot delay 21.9% (n = 34), and equipment backup power failure 13.5% (n = 21). Root causes include issues with backup batteries or equipment, engineering and clinical staff communication, standardized procedures for testing power, backup power delay, electrical circuit issues, documentation, and training. Patient harm occurred in 18% (n = 28) and 3.9% (n = 6) as major or catastrophic. CONCLUSIONS: Power failure during surgery is associated with major or catastrophic patient harm, though rare. Staff preoccupation with failure, disaster preparedness, and focus on communication has the potential to minimize or avoid patient harm.

Identification of microbial signatures linked to oilseed rape yield decline at the landscape scale.

BACKGROUND: The plant microbiome plays a vital role in determining host health and productivity. However, we lack real-world comparative understanding of the factors which shape assembly of its diverse biota, and crucially relationships between microbiota composition and plant health. Here we investigated landscape scale rhizosphere microbial assembly processes in oilseed rape (OSR), the UK's third most cultivated crop by area and the world's third largest source of vegetable oil, which suffers from yield decline associated with the frequency it is grown in rotations. By including 37 conventional farmers' fields with varying OSR rotation frequencies, we present an innovative approach to identify microbial signatures characteristic of microbiomes which are beneficial and harmful to the host. RESULTS: We show that OSR yield decline is linked to rotation frequency in real-world agricultural systems. We demonstrate fundamental differences in the environmental and agronomic drivers of protist, bacterial and fungal communities between root, rhizosphere soil and bulk soil compartments. We further discovered that the assembly of fungi, but neither bacteria nor protists, was influenced by OSR rotation frequency. However, there were individual abundant bacterial OTUs that correlated with either yield or rotation frequency. A variety of fungal and protist pathogens were detected in roots and rhizosphere soil of OSR, and several increased relative abundance in root or rhizosphere compartments as OSR rotation frequency increased. Importantly, the relative abundance of the fungal pathogen Olpidium brassicae both increased with short rotations and was significantly associated with low yield. In contrast, the root endophyte Tetracladium spp. showed the reverse associations with both rotation frequency and yield to O. brassicae, suggesting that they are signatures of a microbiome which benefits the host. We also identified a variety of novel protist and fungal clades which are highly connected within the microbiome and could play a role in determining microbiome composition. CONCLUSIONS: We show that at the landscape scale, OSR crop yield is governed by interplay between complex communities of both pathogens and beneficial biota which is modulated by rotation frequency. Our comprehensive study has identified signatures of dysbiosis within the OSR microbiome, grown in real-world agricultural systems, which could be used in strategies to promote crop yield. Video abstract.

Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide.

OBJECTIVES: The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact. METHODS: As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety. Since May 2012, the National Anesthesia Service subject matter experts, in collaboration with National Center for Patient Safety, review actual adverse events in anesthesiology and detailed lessons learned are developed. A survey of anesthesiology chiefs to determine perceived usefulness and accessibility of the project was conducted in April 2018. RESULTS: The distributed survey yielded a response rate of 69% (84/122). Most of those who have seen the lessons learned (85%, 71/84) found them valuable. Ninety percent of those aware of the lessons learned (64/71) shared them with staff and 75% (53/71) reported a changed or reinforced patient safety behavior in their facility. The lessons learned provided 72% (51/71) of chiefs with new knowledge about patient safety and 75% (53/71) gained new knowledge for preventing adverse events. CONCLUSIONS: This nationwide VHA anesthesiology lessons learned project illustrates the tenets of a learning organization. implementing team and systems-based safeguards to mitigate risk of harm from inevitable human error. Sharing lessons learned provides opportunities for clinician peer-to-peer learning, communication, and proactive approaches to prevent future similar errors.

Suicide and Suicide Attempts on Hospital Grounds and Clinic Areas.

OBJECTIVES: The goal of this study was to describe suicide and suicide attempts that occurred while the patient was on hospital grounds, common spaces, and clinic areas using root cause analysis (RCA) reports of these events in a national health care organization in the United States. METHOD: This is an observational review of all RCA reports of suicide and suicide attempts on hospital grounds, common spaces, and clinic areas in our system between December 1, 1999, and December 31, 2014. Each RCA report was coded for the location of the event, method of self-harm, if the event resulted in a death by suicide, and root causes. RESULTS: We found 47 RCA reports of suicide and suicide attempts occurring on hospital grounds, common spaces, or clinic areas. The most common methods were gunshot, overdose, cutting, and jumping, and we have seen an increase in these events since 2011. The primary root causes were breakdowns in communication, the need for improved psychiatric and medical treatment of suicidal patients, and problems with the physical environment. CONCLUSIONS: Hospital staff should evaluate the environment for suicide hazards, consider prohibiting firearms, assist patients with no appointments, and promote good communication about high-risk patients.

Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem.

OBJECTIVES: The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS: The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken. RESULTS: There were 101 evaluable cases of RGWs. Resident trainee (36%), critical care unit (38%), femoral vein (44%), and nonemergent placement (79%) were the conditions most frequently associated with a RGW. While discovery occurred almost immediately (30%) or in next 24 hours (31%), there were instances of RGWs found months (2%) or years (3%) later. Common root causes included inexperience (46%), lack of standardization (35%), distractions (25%), and lack of a checklist (23%). CONCLUSIONS: The results demonstrate the result of human factors-based errors such as posttask completion errors. We recommend human factor-based interventions such as checklists and devices employing forcing functions that do not allow clinicians to complete the insertion process without first removing the GW.

A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration.

BACKGROUND: Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety. OBJECTIVES: The aim of this retrospective study were to use root cause analysis reports of adverse events occurring in Veterans Health Administration EDs to understand the range of events that were happening and to determine the primary causes of these events as well as actions to prevent them. METHODS: Retrospective safety reports from EDs from Veterans Health Administration medical centers across the nation for a 2-year period (2015-2016) were coded by event type, root cause, and recommended actions. RESULTS: One hundred forty-four cases were included for analysis. The most common adverse events were as follows: delays in care (n = 38, 26.4%), elopements (n = 21, 14.6%), suicide attempts and deaths by suicide (n = 15, 10.4%), inappropriate discharges (n = 15, 10.4%), and errors in following procedures (n = 14, 9.7%). Overall, the most common root cause categories leading to adverse events were knowledge/educational deficits (11.4%), policies/procedures needing improvement (11.1%), and lack of standardized policies/procedures (9.4%). DISCUSSION: Root cause analysis reports are a useful tool to determine the primary systems-based factors of common adverse events in the ED. Recommendations made in this article for addressing these root causes and potentially ameliorating these events will be useful to EDs and related health systems.

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.

Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units.

INTRODUCTION: Suicide is the 10th leading cause of death in the USA. Inpatient suicide is the fourth most common sentinel event reported to the Joint Commission. This study reviewed root cause analysis (RCA) reports of suicide events by hospital unit to provide suicide prevention recommendations for each area. METHODS: This is a retrospective analysis of reported suicide deaths and attempts in the US Veterans Health Administration (VHA) hospitals. We searched the VHA National Center for Patient Safety RCA database for suicide deaths and attempts on inpatient units, outpatient clinics and hospital grounds, between December 1999 and December 2018. RESULTS: We found 847 RCA reports of suicide attempts (n=758) and deaths (n=89) in VHA hospitals, hanging accounted for 71% of deaths on mental health units and 50% of deaths on medical units. Overdose accounted for 55% of deaths and 68% of attempts in residential units and the only method resulting in death in emergency departments. In VHA community living centres, hanging, overdose and asphyxiation accounted for 64% of deaths. Gunshot accounted for 59% of deaths on hospital grounds and 100% of deaths in clinic areas. All inpatient locations cited issues in assessment and treatment of suicidal patients and environmental risk evaluation. CONCLUSIONS: Inpatient mental health and medical units should remove anchor points for hanging where possible. On residential units and emergency departments, assessing suicide risk, conducting thorough contraband searches and maintaining observation of suicidal patients is critical. In community living centres, suicidal patients should be under supervision in an environment free of anchor points, medications and means of asphyxiation. Suicide prevention on hospital grounds and outpatient clinics can be achieved through the control of firearms.