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One of the major issues in improving resident education is the difficulty in collecting data on the results of errors due to exhaustion, inexperience or lack of supervision. While there are many reports and rumors of such incidents, they remain anecdotal and unorganized.
That organizational deficit is about to disappear - at least at the VA. Let me explain.
For many years, commercial pilots have used NASA's Aviation Safety Reporting System (ASRS) to document incidents in which flight safety was compromised due to pilot error, controller error or equipment failure. Incident reports are filed by pilots and flight controllers via ASRS who enjoy total anonimity and immunity except for intentional criminal activity.
The data is compiled and analyzed to elucidate trends that need attention. The FAA can enact new rules or enforce existing rules to ensure that a high degree of safety is maintained throughout the system.
For instance, 3 "near misses" in one week on runways at a single airport indicate a trend at that facility that requires attention.
The VA intends to track medical errors in the same manner that NASA tracks flight safety errors. The VA worked with NASA to design a system similar to ASRS which the VA dubbed the Patient Safety Reporting System (PSRS).
The VA's PSRS will track the following types of incidents:
1. "Close Calls" - events or situations that could have resulted in a patient's accident, injury, or illness, but did not, either by chance or through timely intervention.
2. Unexpected serious occurrences that involved a patient's death, physical injury, or psychological injury.
3. Lessons learned or safety ideas.
In addition, the following types of incidents may be reported without anonimity and immunity guarantees:
1. Intentional criminal acts.
2. Alcohol or substance abuse that impairs staff or provider.
3. Alleged or suspected patient abuse.
For the first time, a large body of data will exist to motivate reforms that will ultimately improve patient safety. If the system is a success, it can be expanded for use in all teaching hospitals.
I anticipate that each of you will become familar with PSRS as you rotate through the VA. The system will work only if you use it.
For more information on the PSRS:
<a href="http://psrs.arc.nasa.gov/web_pubs/04-05-02.htm" target="_blank">http://psrs.arc.nasa.gov/web_pubs/04-05-02.htm</a>
<a href="http://www.psrs.arc.nasa.gov/faq.htm" target="_blank">http://www.psrs.arc.nasa.gov/faq.htm</a>
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That organizational deficit is about to disappear - at least at the VA. Let me explain.
For many years, commercial pilots have used NASA's Aviation Safety Reporting System (ASRS) to document incidents in which flight safety was compromised due to pilot error, controller error or equipment failure. Incident reports are filed by pilots and flight controllers via ASRS who enjoy total anonimity and immunity except for intentional criminal activity.
The data is compiled and analyzed to elucidate trends that need attention. The FAA can enact new rules or enforce existing rules to ensure that a high degree of safety is maintained throughout the system.
For instance, 3 "near misses" in one week on runways at a single airport indicate a trend at that facility that requires attention.
The VA intends to track medical errors in the same manner that NASA tracks flight safety errors. The VA worked with NASA to design a system similar to ASRS which the VA dubbed the Patient Safety Reporting System (PSRS).
The VA's PSRS will track the following types of incidents:
1. "Close Calls" - events or situations that could have resulted in a patient's accident, injury, or illness, but did not, either by chance or through timely intervention.
2. Unexpected serious occurrences that involved a patient's death, physical injury, or psychological injury.
3. Lessons learned or safety ideas.
In addition, the following types of incidents may be reported without anonimity and immunity guarantees:
1. Intentional criminal acts.
2. Alcohol or substance abuse that impairs staff or provider.
3. Alleged or suspected patient abuse.
For the first time, a large body of data will exist to motivate reforms that will ultimately improve patient safety. If the system is a success, it can be expanded for use in all teaching hospitals.
I anticipate that each of you will become familar with PSRS as you rotate through the VA. The system will work only if you use it.
For more information on the PSRS:
<a href="http://psrs.arc.nasa.gov/web_pubs/04-05-02.htm" target="_blank">http://psrs.arc.nasa.gov/web_pubs/04-05-02.htm</a>
<a href="http://www.psrs.arc.nasa.gov/faq.htm" target="_blank">http://www.psrs.arc.nasa.gov/faq.htm</a>
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