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.

Cardiac Telemetry Downtime and Contingency Plan Development: A Review of Downtime Events Reported in the Veterans Health Administration.

BACKGROUND: Cardiac telemetry downtime may be planned or unplanned, causing a disruption in telemetry services with a potential to impact patient safety. PROBLEM: Many cardiac telemetry units in the Veterans Health Administration (VHA) have contingency plans that do not adequately address telemetry downtime. APPROACH: This is a retrospective quality improvement analysis of VHA-reported cardiac telemetry downtime events from October 1, 2014, to Mar 31, 2020. OUTCOMES: Of 98 events, no patient harm was reported; 13% (n = 13) were planned downtime, 82% (n = 80) were unplanned downtime, 18% (n = 18) reported contingency plan use, 78% (n = 76) did not specify contingency plan use, and 32% (n = 31) reported events lasting 31 minutes to 6 hours in duration. CONCLUSIONS: The majority of reported cardiac telemetry downtime events were unplanned and without documented contingency plans. A robust contingency plan with defined staff roles and responsibilities will serve to lessen anxiety during downtimes and mitigate potential risk of patient harm.

Veterans Health Administration Scheduling System: The Path to High Reliability Realization.

EXECUTIVE SUMMARY: Timely access to services is the gateway to patient safety and quality, and scheduling is foundational to providing access to highly reliable care. An effective and efficient scheduling strategy is dependent on an evidence-based approach that focuses on critical drivers of the scheduling system related to patient safety and quality as well as access. As part of a continuing effort to improve access, the Veterans Health Administration (VHA) completed a direct causation analysis (2015-2020) using an evidence-based framework and comprehensive measurement plan. The analysis, described here, validates access benefits realized specialty by specialty and facility by facility, identifies opportunities for improvement, and acknowledges limitations of the change from the Veterans Information Systems and Technology Architecture scheduling system to the Medical Appointment Scheduling System.This analysis of the assessments illustrates business validation structures, drivers, processes, and outcomes that can support leadership decision-making related to access. We drew our assessments of people, processes, policies, and technology from on-site interviews, over-the-shoulder observations, large-group discussions, and data from the VHA Support Service Center and facility data systems; we also mapped process steps, keystrokes, and workflow. Our assessments provided support for the VHA's decision to implement the stand-alone Cerner scheduling system at one site while continuing to implement the Cerner Millennium electronic health record platform that includes the Cerner scheduling system at other VHA sites. The VHA experience provides lessons learned for healthcare leaders who seek highly reliable efforts to improve access to care.

Assessment of unintended volume loss of six closed system transfer devices.

INTRODUCTION: Closed system transfer devices (CSTDs) are used to prepare and administer hazardous drugs. Previous studies have explored the vapor and fluid containment performance of CSTDs. A less obvious consideration is the effect of CSTD use on the intended dose for small volume administrations. We assessed six CSTDs to determine if they contribute to volume loss and delivery of less than the intended dose during simulated drug administration. METHODS: Using an analytical balance, we obtained the mass of each CSTD at four points during simulated drug preparation and subcutaneous administration using sterile water. We used the masses to determine the average volume loss (VL) for each CSTD. RESULTS: Using ANOVA, we identified significant differences in volume loss (VL) among the mean VL (F(6,59) = 18.45, p = 6.19 × 10-12) for the six CSTDs and control (no CSTD). Four CSTDs had a VL that was statistically different than the control (p < 0.05); the VL for two CSTDs was not statistically different than the control (p > 0.05). Volume loss did not depend on administration volume. CONCLUSION: Volume loss performance varied among CSTDs. Volume loss may be clinically significant for small volumes but is not likely clinically significant for larger volumes. It is the authors' opinion that 3 mL represents a reasonable administration threshold below which volume loss should be considered clinically significant. Users should consider volume loss in context of the tasks, drugs, users, and environments where CSTDs will be used. The United States Pharmacopeia (USP) General Chapter <800>: Hazardous Drugs-Handling in Healthcare Settings recognizes the lack of CSTD performance standards. USP <800> recommends independent performance evaluation of CSTDs based on peer-reviewed studies. Our study adds to the comparative performance evaluations of CSTDs available on the market at the time of this review.

The VA Transplant Program: A rebuttal to criticism and a look to the future.

The Department of Veterans Affairs (VA) Transplant Program was established decades ago, is well resourced, and provides timely and high quality solid organ transplant care and services to a Nation of Veterans. In the past few years, the VA Transplant Program has received criticism that can be characterized as follows: the location of VA Transplant Centers (VATCs) requires Veterans to travel considerable distances for transplant care and services; the National Surgery Office (NSO) that provides oversight limits the number of active VATCs; Veterans Health Administration (VHA) policy limits referral of Veterans to non-VA transplant centers (community care); and the VA Transplant Program does not provide living donor transplant procedures. The MISSION Act of 2018 (Public Law 115-182) was enacted in part to address these themes by promoting community care and living donation. This article provides perspective regarding the VA Transplant Program and rebuttal to stated criticism: Travel to a transplant center is not isolated to the VA; the NSO does not limit VATC activation; current VHA policy authorizes community care; and the VA Transplant Program currently performs living donor procedures. The MISSION Act, as intended, has the potential to decrease referrals to the VA Transplant Program by 30%.

Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Enhanced surgical recovery protocols are designed to reduce hospital length of stay and health care costs. OBJECTIVE: This study aims to systematically review and summarize evidence from randomized and controlled clinical trials comparing enhanced recovery protocols versus usual care in adults undergoing elective colorectal surgery with emphasis on recent trials, protocol components, and subgroups for surgical approach and colorectal condition. DATA SOURCES: MEDLINE from 2011 to July 2017; reference lists of existing systematic reviews and included studies were reviewed to identify all eligible trials published before 2011. STUDY SELECTION: English language trials comparing a protocol of preadmission, preoperative, intraoperative, and postoperative components with usual care in adults undergoing elective colorectal surgery were selected. INTERVENTION: The enhanced recovery protocol for colorectal surgery was investigated. MAIN OUTCOME MEASURES: Length of stay, perioperative morbidity, mortality, readmission within 30 days, and surgical site infection were the primary outcomes measured. RESULTS: Twenty-five trials of open or laparoscopic surgery for cancer or noncancer conditions were included. Enhanced recovery protocols consisted of 4 to 18 components. Few studies fully described the various components. Length of stay (mean reduction, 2.6 days; 95% CI, -3.2 to -2.0) and risk of overall perioperative morbidity (risk ratio, 0.66; 95% CI, 0.54-0.80) were lower in enhanced recovery protocol groups than in usual care groups (moderate-quality evidence). All-cause mortality (rare), readmissions, and surgical site infection rates were similar between protocol groups (low-quality evidence). In predefined subgroup analyses, findings did not vary by surgical approach (open vs laparoscopic) or colorectal condition. LIMITATIONS: Protocols varied across studies and little information was provided regarding compliance with, or implementation of, specific protocol components. CONCLUSIONS: Enhanced recovery protocols for adults undergoing colorectal surgery improve patient outcomes with no increase in adverse events. Evidence was insufficient regarding which components, or component combinations, are key to improving patient outcomes. PROSPERO registration number: CRD42017067991.

Data-driven process to improve VA surgical flow.

Purpose During years 2014-2016, Veterans Health Administration National Surgery Office conducted a surgical flow improvement initiative (SFII) to assist low-performing surgery programs to improve their operating room efficiency (ORE). The initiative was co-sponsored by VHA National Surgery Office and VHA Office of Systems Redesign and Improvement. The paper aims to discuss this issue. Design/methodology/approach An SFII algorithm, based on first-time-start (FTS), cancellation rate (CR), lag time (LT) and OR utilization, assigned an ORE performance Level (1-low to 4-high) to each VA Medical Center (VAMC). In total, 15 VAMCs with low-performance surgery programs participated in SFII to assess the current state of their surgical flow processes and used redesign methods to focus on improvement objectives. Findings At the end of the project, 14 VSAs, 40 RPIWs, 45 "90-day projects" and 73 Just-Do-It's were completed with 65 percent (158/243) improvement actions and 86 percent sites improving/sustaining all four ORE metrics. There was a statistically significant difference in improvement across the three stages (baseline, improvement, sustain) for FTS (45.6-68.7 percent; F=44.74; p<0.000); CR (16.1-9.5 percent; F=34.46; p<0.000); LT (63.1-36.3 percent; F=92.00; p<0.000); OR utilization (43.4-57.7 percent; F=6.92; p<0.001) and VAMC level (1.7-3.65; F=80.11; p<0.000). The majority developed "fair to excellent" sustainment (91 percent) and spread (82 percent) plans. The projected annual estimated return-on-investment was $27,949,966. Originality/value The SFII successfully leveraged a small number of faculty, coaches, and industrial engineers to produce significant improvement in ORE across a large national integrated health care network. This strategy can serve healthcare leaders in managing complex healthcare issues in their facilities.

Trends in the Purchase of Surgical Care in the Community by the Veterans Health Administration.

BACKGROUND: The 2014 implementation of the Veterans Choice Program increased opportunities for Veterans to receive care in the community. Although surgical care is a Veterans Health Administration (VHA) priority, little is known about the types of surgeries provided in the VHA versus those referred to community care (CC), and whether Veterans are increasing their use of surgical care through CC with these additional opportunities. OBJECTIVES: To examine national trends across VHA facilities in the frequencies and types of surgeries provided in the VHA and through CC, and explore the association between facilities' purchase of care with rurality and surgical complexity designation. RESEARCH DESIGN: Retrospective study using Veterans Administration (VA) outpatient and CC data from the VA's Corporate Data Warehouse (October 1, 2013-September 30, 2016). MEASURES: Veterans' demographics, outpatient surgeries, facility rurality, and surgical complexity. RESULTS: Our sample included 525,283 outpatient surgeries; 79% occurred in the VHA over the study timeframe. The proportion of CC surgeries increased from 16% in October 2013 to 29% in December 2014, and then subsequently declined, leveling off at 21% in June 2016 (trend, P<0.05). These trends varied by surgery type. Increases in CC surgeries were evident for 4 surgery types: cardiovascular, digestive, eye and ocular, and male genital surgeries (all trends, P<0.05). Rural and low-complexity facilities were more likely to purchase surgical CC than their urban and high-complexity counterparts (P<0.0001). CONCLUSIONS: Although the VHA remains the primary provider of surgical care for Veterans, Veterans Choice Program implementation increased Veterans' use of CC relative to the VHA for certain types of surgeries, potentially bringing challenges to the VHA in delivering and coordinating surgical care across settings.

Using a virtual breakthrough series collaborative to reduce postoperative respiratory failure in 16 Veterans Health Administration hospitals.

BACKGROUND: The Institute for Healthcare Improvement (IHI) Virtual Breakthrough Series (VBTS) process was used in an eight-month (June 2011-January 2012) quality improvement (QI) project to improve care related to reducing postoperative respiratory failure. The VBTS collaborative drew on Patient Safety Indicator 11: Postoperative Respiratory Failure Rate to guide changes in care at the bedside. METHODS: Sixteen Veterans Health Administration hospitals, each representing a regional Veterans Integrated Service Network, participated in the QI project. During the prework phase (initial two months), hospitals formed multidisciplinary teams, selected measures related to their goals, and collected baseline data. The six-month action phase included group conference calls in which the faculty presented clinical background on the topic, discussed evidence-based processes of care, and/or presented content regarding reducing postoperative respiratory failure. During a final, six-month continuous improvement and spread phase, teams were to continue implementing changes as part of their usual processes. RESULTS: The six most commonly reported interventions to reduce postoperative respiratory failure focused on improving incentive spirometer use, documenting implementation of targeted interventions, oral care, standardized orders, early ambulation, and provider education. A few teams reported reduced ICU readmissions for respiratory failure. CONCLUSIONS: The VBTS collaborative helped teams implement process changes to help reduce postoperative respiratory complications. Teams reported initial success at implementing site-specific improvements using real-time data. The VBTS model shows promise for knowledge sharing and efficient multifacility improvement efforts, although long-term sustainability and testing in these and other settings need to be examined.

Development and Validation of the Veterans Health Administration Patient Safety Culture Survey.

RATIONALE, AIMS, AND OBJECTIVES: Patient safety culture (PSC) is an important concept in healthcare organization, and measuring it can lead to improved patient safety event reporting. We sought to test and validate an abbreviated version of a PSC measure within the Veterans Health Administration (VHA). METHODS: An initial set of 34 items was identified to represent the VHA Patient Safety Culture Survey (VHA-PSCS). The items were administered as part of an annual survey administration in June 2019 (N = 205,117, 66.1% response rate). We derived a split-half sample and conducted exploratory and confirmatory factor analysis to identify factors. We examined reliability along with construct and criterion validity of the VHA-PSCS in relation to other workplace attitudes and behaviors. RESULTS: The final instrument includes 20 items with 4 scales derived from factor analysis: (a) risk identification and just culture; (b) error transparency and mitigation; (c) supervisor communication and trust; and (d) team cohesion and engagement. Reliability was supported based on Cronbach α coefficients and split-half testing. For criterion validity, Spearman correlations were greater than 0.40 between VHA-PSCS scales and employee satisfaction and intrinsic work experience. Correlations were greater than 0.20 between VHA-PSC scales and intent to leave, burnout, and self-rated reporting of error incidents. CONCLUSIONS: The VHA-PSCS reflects 4 dimensions of patient safety. The instrument can be used to benchmark and compare progress of VHA's PSC transformation across the organization and within medical centers, to strengthen patient safety event reporting, investigation, and quality of care.

Patient Misidentification Events in the Veterans Health Administration: A Comprehensive Review in the Context of High-Reliability Health Care.

OBJECTIVES: The Veterans Health Administration maintains national patient safety event reporting and root cause analysis (RCA) databases. These were reviewed to understand the prevalence of and provide insight into patient misidentification. The results were compared with a high-reliability health care framework. METHODS: We reviewed patient safety reports and RCA reports to identify and categorize patient identification-related events from October 1, 2016, to September 30, 2018. We analyzed 3232 patient safety reports and 67 RCAs, aggregated the findings, and compared them against The Joint Commission's High Reliability Health Care Maturity Model. RESULTS: Patient misidentification occurred in both inpatient and outpatient settings, for which the ratio of adverse events to close calls was similar. The ratio of adverse events to close calls varied for specific care areas. The most common RCA event characteristic was Two identifiers not used (39%). The most common failure mode was Procedure performed on wrong patient (31%). Issues related to policy and processes accounted for 42% of the root causes. Actions taken were primarily related to policy, process, and staff training/education (56%); these actions were rated as effective by the reporting facilities. CONCLUSIONS: Patient misidentification is prevalent in both the inpatient and outpatient settings. However, specific care areas reported more close calls, an indicator of good safety culture. There were associations between policy and process issues, consistent use of 2 identifiers, and misidentification events. This review provides insight from the Veterans Health Administration national databases that health care institutions can use to improve their systems.

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.

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.

Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review.

OBJECTIVE: To promote a safety culture and reduce harm, health care systems are adopting high-reliability organization (HRO) principles. This rapid review synthesizes HRO frameworks, metrics, and implementation effects to help inform health systems' efforts toward becoming HROs. METHODS: Bibliographic databases were searched from 2010 to 2019. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, extract data, and grade strength of evidence with second reviewer checking. RESULTS: Twenty-three articles were identified: 8 described frameworks, 9 examined metrics, and 9 evaluated implementation outcomes. Five common strategies for HRO implementation emerged (developing leadership, supporting a culture of safety, providing training and learning, building data systems, and implementing quality improvement interventions). The Joint Commission's and Institute for Healthcare Improvement's frameworks emerged as the most comprehensive and widely applicable. The Joint Commission's Oro 2.0 metric for evaluating HRO progress similarly stood out as it was developed through broad stakeholder input and was validated by external researchers. Multicomponent HRO interventions delivered for at least 2 years were associated with improved process and patient safety outcomes. Because each HRO intervention was only supported by a single poor or fair-quality study-none of which contained a concurrent control group-a causal relationship between any HRO initiative and outcomes could not be established. CONCLUSIONS: Health care system adoption of HRO principles is associated with improved safety outcomes, yet the level of evidence is low. Priorities for future HRO studies include use of concurrent control groups and examination of specific outcomes measurements.

A High-Reliability Organization Framework for Health Care: A Multiyear Implementation Strategy and Associated Outcomes.

OBJECTIVES: Applying high-reliability organization (HRO) principles to health care is complex. No consensus exists as to an effective framework for HRO implementation or the direct impact of adoption. METHODS: The Veterans Health Administration (VHA) National Center for Patient Safety established the high-reliability hospital (HRH) model for HRO adoption and piloted HRH in collaboration with the Truman VA Medical Center (Truman) during a 3-year intervention period (January 1, 2016-December 31, 2018). High-reliability hospital components are as follows: annual patient safety (PS) assessment, annual PS culture survey, annual root cause analysis training, daily leadership walk-arounds, monthly PS forum, annual processes standardization review, Just Culture training, unit-based Clinical Team Training, unit-based continuous improvement projects, and annual Clinical Team Training simulation education. The impact of HRH was examined using a PS Culture Survey, PS event reporting, and quality outcomes of standardized mortality rate and complication rate. RESULTS: Truman internally improved PS culture and PS event reporting rates resulting in outcomes better than all VHA facilities (All VHA; P < 0.001 and P < 0.001, respectively). Low-harm PS event reporting increased (P < 0.001); however, serious safety event rate remained unchanged versus All VHA. Significant improvement in Truman standardized mortality rate and complication rate versus All VHA occurred immediately and were sustained through intervention (slopes, P < 0.001 and P < 0.020; respectively). CONCLUSIONS: High-reliability hospital is an effective framework for HRO implementation and will be applied to 18 additional VHA sites. Based on these results, the expected outcome will be improved PS culture and overall PS event reporting. The impact of HRH on serious safety event rate and quality measures requires further study.

Defining core issues in utilizing information technology to improve access: evaluation and research agenda.

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.

Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: a randomized trial.

CONTEXT: Arterial grafts are thought to be better conduits than saphenous vein grafts for coronary artery bypass grafting (CABG) based on experience with using the left internal mammary artery to bypass the left anterior descending coronary artery. The efficacy of the radial artery graft is less clear. OBJECTIVE: To compare 1-year angiographic patency of radial artery grafts vs saphenous vein grafts in patients undergoing elective CABG. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized controlled trial conducted from February 2003 to February 2009 at 11 Veterans Affairs medical centers among 757 participants (99% men) undergoing first-time elective CABG. INTERVENTIONS: The left internal mammary artery was used to preferentially graft the left anterior descending coronary artery whenever possible; the best remaining recipient vessel was randomized to radial artery vs saphenous vein graft. MAIN OUTCOME MEASURES: The primary end point was angiographic graft patency at 1 year after CABG. Secondary end points included angiographic graft patency at 1 week after CABG, myocardial infarction, stroke, repeat revascularization, and death. RESULTS: Analysis included 733 patients (366 in the radial artery group, 367 in the saphenous vein group). There was no significant difference in study graft patency at 1 year after CABG (radial artery, 238/266; 89%; 95% confidence interval [CI], 86%-93%; saphenous vein, 239/269; 89%; 95% CI, 85%-93%; adjusted OR, 0.99; 95% CI, 0.56-1.74; P = .98). There were no significant differences in the secondary end points. CONCLUSION: Among Veterans Affairs patients undergoing first-time elective CABG, the use of a radial artery graft compared with saphenous vein graft did not result in greater 1-year patency. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00054847.

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.

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.