Senior officials signed an agreement creating the VA Patient Safety Reporting System, in which NASA will analyze information about medical errors at VA hospitals
The 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
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,
"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 $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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