Veterans Affairs National Center

National Center for Patient Safety (NCPS). 2001a. Healthcare failure mode and effect analysis. In Strategies for Leadership. Ann Arbor, MI Department of Veterans Affairs, National Center for Patient Safety. 

An exemplar of accountability is the Veterans Affairs system that, under the leadership of Dr. Ken Kizer, established the Veterans Affairs National Center for Patient Safety. Kizer chose physician and former space shuttle astronaut James Bagian to lead both the center and a relentless, evidence-based campaign to eliminate harm across the 170-hospital VA system and to test new technologies and interventions to make health care safer. While at the VA, Dr. Nancy Wilson developed a culture survey. This leadership tool evaluates whether specific tactics are in place to advance the culture of safety. The survey measures leadership and strategy, and it includes the following dimensions (Wilson, 2000) ... 

Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA Cristina Solveira EuroEspes Biomedical Research Center, Institute for CNS Disorders and Genomic Medicine, Camilo Jose Cela University, Madrid, Spain Catherine J. Spellicy Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA... 

Born in 1965 in Utrecht, the Netherlands, Marjolein van der Meulen received her Bachelors degree in mechanical engineering from the Massachusetts Institute of Technology in 1987. Thereafter, she received her MS (1989) and PhD (1993) from Stanford University. She spent three years as a biomedical engineer at the Rehabilitation R D Center of the Department of Veterans Affairs in Palo Alto, CA. In 1996, Marjolein joined the faculty of Cornell University as an Assistant Professor in the Sibley School of Mechanical and Aerospace Engineering. She is also an Assistant Scientist at the Hospital for Special Surgery, New York. She received a FIRST Award from the National Institutes of Health in 1995 and a Faculty Early Career Development Award from the National Science Foundation in 1999. Her scientific interests include skeletal mechanobiology and bone structural behavior. 

In the second study, Ruscio, Ruscio, and Keane (2002) examined the taxonicity of PTSD in a large sample of male combat veterans (N = 1,230), who were seen at the Behavioral Sciences Division of the Veterans Affairs Boston Healthcare System s National Center for posttraumatic stress disorder between 1985 and 2000. All the participants completed the Mississippi scale (Keane, Caddell,. Taylor, 1988), a 35-item measure of combat-related posttraumatic stress disorder symptoms rated on a five-point scale a subset of this sample (n = 841) was assessed with the Clinician Administered Posttraumatic Stress Disorder Scale (CAPS), an interview measure of posttraumatic stress disorder symptoms that a clinician rates on a five-point scale. According to the CAPS, 68% of the sample qualified for a posttraumatic stress disorder diagnosis. 

It s a promising way to automate aspects of medication administration, says Robert Krawisz, former executive director of the National Patient Safety Foundation. The technology s impact at VA hospitals so far has been amazing. The Department of Veterans Affairs (VA) already uses bar codes nationwide in its hospitals, and the result has been a drastic reduction in medication errors. For example, the VA medical center in Topeka, Kan., has reported that bar coding reduced its medication error rate by 86 percent over a nine-year period. 

We thank W.E. Franklin, B.D. Fink, J.L. Delp and C.A. Russo for technical assistance. This work was supported by the following grants to R.L. Veterans Affairs Merit Review Award, National Science Foundation Grant BNS-8917665, and the Diabetes-Endocrinology Center Grant DK-25295. 

Dr. Ohiin is presently a member of the American National Standards Institute Working Group S12A/VG11, a member of the Advisory Board to the National Research Center for Rehabilitative Auditory Research for Veterans Affairs and a contract consultant to 3M Company. 

This research was supported by the Veterans Affairs Merit Review grant and in part by an unrestricted Educational Research grant from Pharmacia Inc. to N. Ravi. Mass spectrometry was provided by the Washington University Mass Spectrometry Resource with support from the NIH National Center for Research Resources (Grant No. P41RR0954). The authors would like to thank Mr. P. Hamilton for his support with the dimensional stability measurements. 

---