Diagnosing errors at VA

The Department of Veterans Affairs plans to use a new reporting system operated

by NASA to obtain information about medical errors at VA hospitals and improve

the overall safety of VA medical treatment.

NASA will develop a system to collect reports of health care errors

and close calls and send the information to medical teams administering

VA health care.

Senior NASA and VA officials signed the agreement that will create the

VA Patient Safety Reporting System (PSRS) on May 30. The system comes in

response to a report released in November by the Institute of Medicine that

said that more than 90,000 Americans die every year as a result of preventable

medical errors.

The report urged the VA to use as a model the Aviation Safety Reporting

System (ASRS), which NASA has operated for the Federal Aviation Administration

since 1976.

"Most errors in medicine are the result of faulty systems" rather than

from those committed by employees, said Thomas Garthwaite, acting undersecretary

for health at the VA. "If you don't know about it, you can't fix it."

Garthwaite hopes the anonymity of the external, voluntary system NASA

will administer will encourage staff members to report problems. The VA

also has an internal, mandatory reporting system, he said.

The VA and NASA plan to begin accepting reports into the system at the

beginning of 2001, said James Bagian, director of the VA's National Center

for Patient Safety. The team is looking at how to construct the database,

locate staff, educate stakeholders and debug and test the system, he said.

"The real message, if you look at safety-oriented cultures and industries,

is..."Don't wait for the train wreck to fix it,' " Bagian said.

The key is not labeling someone as being at fault, he added. "If you

stop there, you've missed the way to improve the system," he said. "You

need to know what happened, when it happened and why it happened."

For instance, the database will help the VA identify design issues

that contribute to errors using medical instruments, he said.

The 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, said Henry McDonald, director of NASA's Ames Research Center.

"The success of the Aviation Safety Reporting System leads us to believe

we have a great deal to offer to PSRS," McDonald said.

ASRS receives 35,000 reports per year and issues about 20 alerts per

month, said Linda Connell, system director. The reports are analyzed by

a team of 10 retired pilots and air traffic controllers.

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