Florida Health Information Center
&
Suncoast Center for Patient Safety

VA National Patient Safety Center of Inquiry at Tampa

Areas of Emphasis

    The Department of Veteran's Affairs awarded over a million dollars over three years to the James A. Haley Veterans Hospital, Tampa to establish a Patient Safety Center of Inquiry. The focus of this Center is to (1) support clinicians in providing safe patient care, and (2) improve functional status and quality of life for frail elderly and persons with disabilities by addressing issues related to safe mobility.

    The Center has been established to address global issues related to patient safety. Activities pertaining to the first area of focus include: redesigning patient safety reporting strategies to allow for electronic data entry, standardizing reporting procedures, establishing a model patient and staff education program, and designing a web-based dedicated system for information dissemination and training.

    The second area of focus targets safety related to mobility for vulnerable patient populations, including persons with physical disabilities and the frail elderly. Our new biomechanics research laboratory enables us to research patient falls, safe wheelchair transfers, and prevention of pressure ulcers.

     The mission of the Center is to improve patient safety by building infrastructure and information systems to support clinicians in providing safe patient care and to improve functional status and quality of life for frail elderly persons with disabilities by addressing issues related to safe mobility.

     The center is comprised of four divisions: (1) Clinical Care, (2) Patient Safety Improvement, (3) Technology, and (4) Dissemination. Several projects have been identified for each division that address the mission of the center.

Patient Safety Improvement

     The Florida Health Information Center has been working with the VA National Patient Safety Center of Inquiry at Tampa (VA PSCI) on some of their research initiatives. The overall thrust of the VA PSCI, under the direction of Audrey Nelson, RN, PhD, is on mobility issues, specifically mobility of the disabled and frail elderly.

    Dr. Jay Wolfson is Associate Director of Division #2: Patient Safety Improvement (Risk Management) within the VA PSCI. The Patient Safety Improvement Division is involved in developing infrastructure and information systems to support patient safety.

    Key Projects of Division 2

1) Design a model risk management program, standardizing procedures
2) Design an Information System to support risk management
3) Establish an Investigative Panel for Sentinel Events
4) Conduct an ethnographic study to define errors and identify barriers to reporting patient safety incidents or near misses
5) Conduct economic analyses to identify costs, determine cost benefit or evaluate cost effectiveness of proposed innovations related to safe mobility for frail elderly and persons with disabilities

     The FHIC has been working closely with the VA PSCI at Tampa, as well as the VA National Patient Safety Center on a number of innovative programs to accomplish the goals of the Division and the VA PSCI.

• Organizing a Patient Safety Improvement Board Conference to develop workplans for achieving the divsion objectives
• Piloting of VHA National Patient Safety Improvement Handbook developed by the VA National Patient Safety Center
• Piloting of a Culture Assessment Questionnaire to monitor changing organizational culture
• Development and Piloting of reporting forms of a de-identified incident reporting system
• Developing an incident reporting system and confidential database repository
  

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