Health care policy - VA National Center for Patient …
Introducing our new director, Robin Hemphill, M.D. By Joe Murphy, M.S., A.P.R., NCPS public affairs officer. On April 25, 2011, Dr. Hemphill became . the deputy chief patient safety officer and direc-tor, National Center for Patient Safety. She is also continuing her practice as an emergen-
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Root Cause Analysis (RCA) Process Steps.
www.patientsafety.va.govRoot Cause Analysis (RCA) Step-By-Step Guide RCA is a process for identifying the basic or contributing causal factors that underlie variations in performance
The Basics of Healthcare Failure Mode and Effect Analysis
www.patientsafety.va.gov2 What is Failure Mode and Effect Analysis? Failure Mode and Effect Analysis (FMEA) is a systematic method of identifying and preventing product and process problems before they
Using Health Care Failure Mode and Effect Analysis™
www.patientsafety.va.govFailure Mode and Effect Analysis (HFMEA™). Key aspects of the HFMEA™ process: HFMEA™ is a 5-step process that uses an interdiscipli-nary team to proactively evaluate a health care process. The team uses process flow diagramming, a Hazard Scoring Matrix™, and the HFMEA Decision Tree™ to
MODERATE SEDATION BY NON-ANESTHESIA PROVIDERS 1. …
www.patientsafety.va.govVeterans Health Administration Transmittal Sheet . Washington, DC 20420 December 30, 2014 . MODERATE SEDATION BY NON-ANESTHESIA PROVIDERS 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Directive establishes the policy that defines the provision of moderate sedation by providers other than Anesthesiologists and Nurse Anesthetists. 2.
Guide to Performing a Root Cause Analysis (Revision 02/05 ...
www.patientsafety.va.govThe most commonly used comprehensive systematic analysis is the Root Cause Analysis (RCA). The RCA is a process for identifying the basic causal factor(s) underlying system failures and is a widely understood methodology used in many industries. Root cause analysis can be used to uncover factors that lead to patient
Guide to Performing a Root Cause Analysis (Revision 10-20 ...
www.patientsafety.va.govThe most commonly used comprehensive systematic analysis is the Root Cause Analysis (RCA). The RCA is a process for identifying the basic causal factor(s) underlying system failures and is a widely understood methodology used in many industries. Root cause analysis can be used to uncover factors that lead to patient
Just Culture - Veterans Affairs
www.patientsafety.va.govJust Culture: A Just and Fair Culture is a necessary component of a Culture of Safety. A Just and Fair Culture is one that learns and improves by openly identifying and examining its own weaknesses; it is transparent in that those within it are as willing to expose weaknesses as they are to expose areas of excellence. In a Just Culture,
Falls Policy Overview - Veterans Affairs
www.patientsafety.va.govFalls Policy Overview The following is a suggested falls prevention policy. It is not required to be implemented. There are several areas that need to be covered in a falls prevention policy: I. Definitions of a Fall, Type of Falls, Severity of Injury . II. Fall Risk Assessment for Inpatients . III. Fall Risk Assessment for Outpatients . IV.
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