VA Targets Safer Medical Care

WASHINGTON (05/31/2000) - The U.S. Department of Veterans Affairs plans to use a system operated by NASA to obtain information about medical errors at VA hospitals and improve the overall safety of VA medical treatment.

Senior NASA and VA officials on Tuesday signed an agreement creating the VA Patient Safety Reporting System. The system is a response to a report titled "To Err is Human: Building a Safer Health System" that was released in November by the Institute of Medicine. The report said that more than 90,000 Americans die every year because of preventable medical errors.

NASA, which has operated a similar aviation safety reporting system (ASRS) for the Federal Aviation Administration since 1976, will develop an external system to collect reports of health care errors and close calls and disseminate information to the medical teams administering VA health care.

The Institute of Medicine report identified a number of opportunities to reduce the consequences and urged the VA to use the ASRS designed by NASA for FAA as a model.

"Most errors in medicine are the result of faulty systems" rather than employees, said Thomas Garthwaite, acting undersecretary for health at VA. "If you don't know about it, you can't fix it."

Garthwaite hopes the anonymity of the voluntary system NASA will administer will encourage staff members to report problems. VA also has an internal mandatory reporting system, he said.

VA and NASA plan to begin accepting reports into the system at the beginning of 2001, said James Bagian, director of VA's National Center for Patient Safety.

The team is looking at how to construct the database, locate staff, educate and invite stakeholders to participate and debug and test the system, he said.

"The real message if you look at safety-oriented cultures and industries is they don't wait for the train wreck to fix it," Bagian said.

For instance, the database will help VA identify design issues that contribute to errors using medical instruments, he said.

VA will provide NASA US$8.2 million for the development of a prototype by 2003.

NASA will staff the system and develop software tools for mining the data for useful trends, said Henry McDonald, director of NASA's Ames Research Center.

Ames is NASA's Center of Excellence for information technology.

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