VA PA Sim Center

Patient Safety Center of Inquiry at VA Palo Alto Health Care System

The Patient Safety Center of Inquiry (PSCI) at VA Palo Alto Health Care System (VAPAHCS) was activated on April 1, 1999 and in order to serve the following goals:

PSCI will address six issue areas:

Summary of PSCI's Tracks of Activity

Track 1 - Theory of Organizational Safety

This track is directed by Dr David Gaba whose interest in this field begun under the aegis of a Robert Wood Johnson Grant. This track investigates the following issues:

Track 2 - Teamwork and Simulation

The Teamwork and Simulation track is directed by Dr. Kevin Fish, Chief, Anesthesiology Service, VAPAHCS. Dr. Fish is one of the originators of simulation-based teamwork training, and a co-author of the textbook "Crisis Management in Anesthesiology". This track includes simulation-based crisis management training activities in the operating room (ACRM), intensive care unit (Improvement of Management of Patient Emergency Situations or IMPES, and the delivery room (Neo/CRM). This track will soon include other activities related to management of patient trauma and emergency medicine and surgery.

Track 3 - Fatigue Effects on Clinicians

This track is directed by Dr. Steve Howard and it investigates issues related to fatigue of health care practitioners and its impact on patient safety. Dr. Howard is a leading expert in this field and has conducted previous studies on fatigue of anesthesia providers in the operating room. Currently Dr. Howard is collaborating with the departments of surgery, emergency and internal medicines, and nursing to establish fatigue measurement tools and recommendations for improving health care providers' rest conditions in order to optimize patient safety.

Track 4 - Cultures of Safety

This track is directed by Dr Gaba and is being lead by Kim Park, RN, from Quality Management at the VAPAHCS. A new survey instrument on cultures of safety was developed, combining elements from four pre-existing surveys to capture elements of assessing cultures of safety in the health care industry.

Using this instrument, a survey at the VAPAHCS, at other VA facilities in VISN 21, and in other VISNs was conducted. This survey will investigate the following hypotheses:

Track 5 - Event Reporting and Analysis

Dr. Gaba has conducted a large review of existing reporting systems in health care and in other high-hazard industries, and of the key issues governing the success or failure of such systems. Dr. Gaba and PSCI's investigators serve as consultants on the VHA pilot project to create a Patient Safety Reporting System (PSRS) analogous to the Aviation Safety Reporting System run by NASA for the FAA.

Track 6 - Protection of the Safety of Human Subjects in Research

Recent developments at West LA VA and Duke University as well as reports of the National Bioethics Advisory Committee have focused increasing attention and concern on the protection of the safety of human research subjects. This area has not been considered previously a priority of patient safety research or intervention. In this track, the PSCI at VAPAHCS has a unique opportunity to incorporate these emerging concerns into the framework of organizational safety and the patient safety movement due to the fact that the PSCI Director, Dr. Gaba, also chairs one of two IRBs covering medical research at VAPAHCS and Stanford University.

The connections between protection of research subjects and patient safety in general are important: on the one hand, it offers lessons from the philosophy and processes put in place to protect research subjects; on the other hand, the safety of research subjects needs to be viewed relative to the safety of patients as a whole. Emerging issues being explored by PSCI include:


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