Diagnosing errors at VA
- By Paula Shaki Trimble
- Jun 05, 2000
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
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
"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.