Objectives: The Department of Veterans Affairs has transformed its approach to dealing with medical injuries, directing caregivers to inform patients of injuries and internally reporting errors and near misses for analysis and improvement of patient safety. Resistance occurs in changing front-line caregivers' attitudes about errors and injury reporting even in the VA's protected institutional environment, however. For purposes of dissemination, it is important to consider differences and similarities between the VA and private sector medical, institutional, and legal environments.
Study Design: Review of VA experience, focus groups with front-line caregivers and policy analysis of VA environment.
Population Studied: Department of Veterans Affairs executives, middle managers, and caregivers.
Principal Findings and Conclusions: Perceptions differ by level within the organization. Formal rules are seen to differ from informal practice. Within the VA, budgetary allocations are an important indicator of seriousness of initiatives. Leadership, substantial resources including time, and sensitivity to front-line cultures are needed to effect change.
Implications for Policy, Delivery or Practice: Changing culture is hard work, but feasible. Careful attention to institutional context is needed to transfer across sectors. Announced policies may be very difficult to implement in practice.
Learning Objectives: At the conclusion of the session, participants will be able to: the types of patient injury at issue in current policy discussions about patient protection, patient safety, and medical error, particularly in the outpatient setting. understand some of what is known about the factors underlying injry and promoting or inhibiting efforts at prevention articulate the policy options available -- public and private, legal and other -- to ameliorate medical injuries understand the emerging state of evidence about errors, injury and prevention. identify the relative strengths and weaknesses of differing approaches consider whether their career or their research can make a contribution to improving such outcomes
Keywords: Injury Prevention, Health Law
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.