VA heal thyself:
VA technology applies balm to patient safety issues
By Shelia Watson
Contributing Writer
Judging by several recent patient safety studies, the physician’s credo “First, do no harm” may be lost under the staggering number of medical and prescription errors reported over the last decade.
A governmental mandate to reduce those errors is the driving force behind the Department of Veterans Affairs seeking a cure for lax patient safety.
It’s not as if no one had noticed how bad things were. In 1999, a report by the Institute of Medicine, entitled “To Err is Human: Building a Safer Health System,” unnerved the health care industry and fueled efforts toward improved patient safety measures across the country.
And yet, by the time the IOM released its report, which stated that “as many as 98,000 die per year due to medical errors in hospitals,” the U.S. Department of Veterans Affairs was already setting new standards for a health care system.
The VA had formed a panel of experts in 1997 to address patient safety and a year later formed the National Center for Patient Safety, which develops and maintains safe practices throughout the organization.
“Essentially, what we’ve done is look at the process and figure out how to make it ‘people-proof,’” said Dr. Florence N. Hutchinson, acting director of the Ralph H. Johnson VA Medical Center in Charleston. “People are human, they make errors, but they can learn how to do things better, too.”
Through its patient safety program, the VA has introduced significant changes in staff attitudes, beliefs and behavior, all designed to produce a cultural change to improve patient safety. In testimony before Congress in 2000, the Government Accountability Office suggested the program could be more successful if greater attention were paid to leadership strategies as outlined in the IOM report.
GAO testimony noted that “the VA could also better ensure success if it prepared a detailed implementation plan that identifies how and when VA’s various patient safety programs will be implemented, how they are aligned to support improved patient safety and what contribution each program can be expected to make toward the goal of improved patient safety.”
Naturally such a mandate would require measurement tools, which would require a technology component, which in turn gave birth to VISTA—the Veterans Health Information Systems and Technology Architecture, a group of software modules that covers a range of health care applications.
Patient records in VISTA are fully electronic, portable and easily accessible. CT scans, MRIs and EKGs are available for 3-D and 360-degree viewing with one click. Immediate accessibility to complete records helps ensure patient safety, especially with the alerts and reminders built into the system.
Physician, report thyself
Another area where the VA is setting the pace is in reporting problems.
In the health care field, many “close calls” or “near misses” often are not formally reported or analyzed because medical personnel may be hesitant to disclose adverse events. Hence, valuable information that could be used to diagnose system weaknesses and prevent future errors is lost, Hutchinson explained.
“Early in the ’90s, the VA contracted with NASA to come up with a safety reporting system that was based on the aviation system of reporting problems,” she said.
The Patient Safety Reporting System is an external, voluntary, confidential and non-punitive system intended to provide a “safety valve” for those who are not comfortable reporting adverse events or close calls. The information can be provided electronically with anonymity.
“The point is to make it OK for people to report that something is wrong or almost went wrong,” she said. “It’s a system of making it easier to do the right thing.”
Setting the barcode
The VA also is leading the way in prescription safety. A July 2006 study by the IOM noted that more than 1.5 million Americans are injured by medication errors every year. About 400,000 preventable drug errors occur in hospitals, which result in $3.5 billion in hospital costs alone.
To combat those statistics, the VA has implemented a system in which patient information is retrieved through a barcode scan at the time the medicine is administered, even for refills after the patient leaves the hospital.
“You scan the bracelet with the barcode and that will call up the patient’s information on the computer,” said Tonya Lobbestael, public affairs officer for the RHJ VA. “There are even photos on the bracelet so you can make a positive ID of the person.”
The IOM study, which was requested by Congress, recommended that all prescriptions be written electronically by 2010, a suggestion many health care professional applaud.
“One of our biggest sources of error is verbal communication,” said Hutchinson. “Think about how close the two drugs sound when I say ‘hydroxyzine’ (used to relieve itching from allergies as well as effects of motion sickness) and ‘hydralazine’ (used to treat high blood pressure). But the difference could be deadly for someone taking the wrong thing.”
The system appears to be working. According to a 2004 study by RAND Corp., 3% to 8% of prescriptions throughout the country are filled incorrectly, yet the VA’s accuracy rate on prescriptions is 99.997%.
The system of improved information technology, tracking of performance and accountability gives the VA an edge in the health care field. Today, the IOM refers to the VA’s health care system as one of the best in the world. Private health care facilities are taking note, hoping to adopt the system. If they do, the savings could be worth the effort: Another RAND study in September 2005 showed that successful adoption of health information technology by 90% of doctors and hospitals could cut health care spending by $77 billion annually.
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