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Biomedical subjects

James P Bagian

Publications and source records attributed to James P Bagian.

12 recordsLinked to original sources
PubMed2006

Patient safety: lessons learned.

The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report "To Err Is Human: Building a Safer Health System." However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence "shame and blame") to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.

Delivery of Health Care↗
PubMed2006

Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement. OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO. DESIGN: Six Sigma Project with pre-post design. PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals. MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire. RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products. CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

Centers for Disease Control and Prevention, U.S.↗
PubMed2005

Patient safety: what is really at issue?

The Veterans Health Administration found that a number of components were key to implementing a meaningful and effective patient safety program. To truly improve patient safety, the overall goal of your organization must be to prevent harm to the patient, not to eliminate errors. Create a system that is perceived as fair, and mitigate perceived barriers to improving patient safety. Create a transparent system for prioritizing and establishing how resources will be applied to the patient safety effort. Provide tools that support root cause analysis that moves beyond superficial and inadequate questions such as, Whose fault is this? Action that results in improvement, not simply analysis of the problem, is needed. Finally, leadership and management must be visibly involved in the patient safety program.

Attitude of Health Personnel↗
PubMed2004

A cognitive aid for cardiac arrest: you can't use it if you don't know about it.

BACKGROUND: A cognitive aid developed by the Department of Veterans Affairs (VA) and distributed to all VA facilities provides caregivers with information to minimize omission of critical steps when diagnosing and treating cardiac arrest. In 2002, caregivers were surveyed about the usefulness of the cognitive aid and the success of its dissemination throughout the VA. METHODS: Fifty randomly selected VA hospitals were sent a letter to alert them of the upcoming survey. Twenty surveys were sent to each of the selected hospitals with instructions to distribute the survey to specific caregiver types. RESULTS: Nine (18%) of the VA hospitals had not used the cognitive aid tool because of dissemination problems. Of the 565 caregivers responding to the survey, 59% (332) were aware of the cognitive aid. Of these 332, 96% agreed that putting the cognitive aid on code carts is a good idea. There were 234 respondents who were both aware of the cognitive aid and had been involved in at least one code within the past 30 days. Of these 234, some 29 (12%) used the aid during a code, 28 of whom agreed that the cognitive aid was helpful during the code. DISCUSSION: Both new and experienced caregivers find the cognitive aid helpful when responding to "code" situations. However, cognitive aids cannot be helpful if theintended users are unaware of their availability. Dissemination and awareness of the aids can be problematic in large health care systems.

Audiovisual Aids↗
PubMed2002

The Veterans Affairs root cause analysis system in action.

BACKGROUND: The patient safety program in the Department of Veterans Affairs (VA) began in 1998, when the National Center for Patient Safety (NCPS) was established to lead the effort on a day-to-day basis. NCPS provides the structure, training, and tools, and VA facilities provide front-line expertise, feedback about the process, and root cause analysis (RCA) of adverse events and close calls. MONITORING THE PROCESS: Facility patient safety managers determine the disposition of adverse events and close calls occurring at their facilities. They use a safety assessment code (SAC) to prioritize the actual and potential severity and frequency of an event. BEFORE-AND-AFTER STUDY: Before the new RCA system was implemented in 2000, the VA used another adverse event reporting system, focused review (FR). A comparison of the two processes indicates that the RCA process has shifted analyses of adverse events toward a human factors engineering approach-entailing a search for system vulnerabilities rather than human errors and other less actionable root causes. CASE EXAMPLES: Two case examples--on hazards in the magnetic resonance imaging (MRI) room and on a cardiac pacemaker malfunction--illustrate how the RCA system works in actual operation. The cases illustrate that broadly applicable, high-impact actions can result from a thorough RCA process. DISCUSSION: NCPS monitors the quality and completeness of RCAs through the immediate review and feedback process. Still to be investigated is the effectiveness of RCA actions addressing the hypothesized root causes and contributing factors of the close calls and adverse events.

Accidental Falls↗
PubMed2002

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety.

BACKGROUND: In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities. A NOVEL APPROACH: To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond. KEY ACTION ITEMS AND RESULTS RELATED TO RCA: NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.

Awards and Prizes↗
PubMed2002

Department of Veterans Affairs patient safety program.

The Department of Veterans Affairs (VA) has been recognized for its patient safety initiatives. In 1998, a separate entity entitled the National Center for Patient Safety (NCPS) was established to promulgate and nurture the patient safety activities throughout the health care facilities of the VA. On the basis of a nonpunitive approach, NCPS fosters a culture of safety whereby clinicians report unsafe situations and close calls without fear of reprisals. The VA patient safety program stresses that reducing iatrogenic injury is best served through an examination of system and process vulnerabilities, with a focus on why something occurred rather than who is at fault. This article discusses the genesis of the VA patient safety program and reviews some of its successes.

Humans↗
PubMedDate not supplied

James P. Bagian on patient safety initiatives. Interview by Deborah Mears.

James P. Bagian, MD, is director of the Veterans Health Administration (VHA) National Center for Patient Safety (NCPS). With a focus on systems and an emphasis on "prevention not punishment," NCPS is working to improve patient safety, prevent health care errors, and nurture a culture of safety throughout the 173 VHA medical centers. Previously, Dr. Bagian served as deputy director of the Regional and State Programs Division, Office of Mobile Sources, Environmental Protection Agency. From 1980 to 1995, Dr. Bagian served as a NASA astronaut. He took part in both the planning and provision of emergency medical and rescue support for the first six Space Shuttle flights. In 1986, Dr. Bagian served as an investigator for the Space Shuttle Challenger accident. A veteran of two space flights (STS-29 in 1989 and STS-40 in 1991), Dr. Bagian has logged more than 337 hours in space. Dr. Bagian is currently an adjunct assistant professor of military and emergency medicine at the Uniformed Services University of Health Sciences at F. Edward Herbert School of Medicine and also a clinical assistant professor of preventive medicine and community health at the University of Texas Medical Branch. He is a Colonel in the U.S. Air Force Reserve where he is a pararescue flight surgeon with the 920th Air Rescue Group. He has received the American Medical Association's Nathan S. Davis Award for outstanding public service in the advancement of public health. The NCPS received the 2001 Innovations in American Government Award given by the Institute for Government Innovation at the John F. Kennedy School of Government of Harvard University. The NCPS was the only federal organization to be so identified in 2001.

Hospitals, Veterans↗