Improving Patient Safety through Educational Initiatives

Abstract

The VA National Center for Patient Safety (NCPS) came into being just prior to publication of the IOM Report (Kohn, 1999). From the outset, the approach used by NCPS was to seek engineering solutions (Watts, 2012). Human factors engineering (HFE) adds the necessary insight for solving complex patient safety issues (Bagian, 2012; Gurses, 2012). For NCPS, the initial step was development of a specialized professional role, a Patient Safety Manager, employed at every VA hospital [Bagian, 2002]. A second effort, detailed here, is specifically focused on filling a patient safety leadership gap. Clinician-leaders become patient safety leaders as they acquire knowledge and skills in teamwork, communication, and other HFE-based methods for problem-solving.