VA targets safer medical care

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,

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 $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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