scholarly journals Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses

2021 ◽  
pp. 78-91
Author(s):  
Elizabeth Lancaster ◽  
Elizabeth Rhodus ◽  
Mary Duke ◽  
Andrew Harris
Keyword(s):  
Blood Transfusion ◽  
Time Frame ◽  
Veterans Health ◽  
Health Administration ◽  
Patient Identification ◽  
Technology Barriers ◽  
Root Cause ◽  
System A ◽  
Sentinel Events ◽  
Standard Practices

Introduction: Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process. Methods: This study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 RCAs and aggregated reviews were included in the study. These were reviewed for common themes and gaps present within processes. Results: The most common events fell within the categories of incorrect or delayed blood orders, incorrect or lack of patient identification, and wrong blood given. The RCA for each event was reviewed and studied. The RCAs had a crossover of multiple causes; lack of a formal process, communication barriers, and technology barriers were the most frequent. Conclusion: These RCAs express great variation between VHA facilities, such as process created, number of staff reports, and number of RCAs completed. Lack of standard practices nationwide, training barriers, and technology barriers may explain the variation of transfusion errors throughout the VHA. This study brings to light questions about standardization of transfusion protocols. Future study regarding such standardization is necessary to determine its plausibility.

scholarly journals Carbon Monoxide Poisoning in the Veterans Health Administration, 2010 - 2016

2017 ◽  
Vol 9 (1) ◽  
Author(s):  
Gina Oda ◽  
Russell Ryono ◽  
Cynthia A. Lucero-Obusan ◽  
Patricia Schirmer ◽  
Mark Holodniy
Keyword(s):  
Carbon Monoxide ◽  
Carbon Monoxide Poisoning ◽  
Veterans Health Administration ◽  
The United States ◽  
Time Frame ◽  
Urgent Care ◽  
Veterans Health ◽  
Co Poisoning ◽  
Health Administration ◽  
Self Harm

ObjectiveTo describe characteristics of Veterans Health Administration(VHA) patients with ICD 9/10 CM inpatient discharge and/oremergency department (ED)/urgent care outpatient encounter codesfor carbon monoxide (CO) poisoning.IntroductionIt is estimated that in the United States (US), unintentional non-firerelated CO poisoning causes an average of 439 deaths annually, and in2007 confirmed CO poisoning cases resulted in 21,304 ED visits and2,302 hospitalizations (71 per million and 8 per million population,respectively)1. Despite the significant risk of morbidity and mortalityassociated with CO poisoning, existing surveillance systems in theUnited States are limited. This study is the first to focus specificallyon CO poisoning trends within the VHA population.MethodsQueries were performed in VA PraedicoTMPublic HealthSurveillance System for inpatient discharges and emergency roomand urgent care outpatient visits with ICD 9/10 CM codes for COpoisoning from 1/1/2010 – 6/30/2016. A dataset of unique patientencounters with CO poisoning was compiled and further classified asaccidental, self-harm or unspecified. Patients with carboxyhemoglobin(COHb) blood level measurements≥10%2for the same timeframewere extracted and merged with the CO poisoning dataset.We analyzed for demographic, geographic and seasonal variables.Rates were calculated using total unique users of VHA care formatching time frame and geographic area as denominators.ResultsThere were a total of 671 unique VHA patients identified with COpoisoning. Of these, 298 (44%) were classified as accidental, 104(15%) self-harm, and 269 (40%) unspecified. A total of 6 patientsdied within 30 days of their coded diagnosis, however only 1 ofthese was directly attributable to CO poisoning. The overall rate ofCO poisoning over the study time frame was 18 per million uniqueusers of VHA care. CO poisoning diagnoses were obtained from396 (59%) outpatients, 216 (32%) inpatients, and 59 (9%) patientswith both and outpatient visit and inpatient admission. Patientswith self-harm classification were less likely to be seen in the ED(only 24 (6%) unique patients compared to 190 (48%) accidental and182 (46%) unspecified classifications). Of patients seen in the ED andsubsequently admitted, patients with the classification of accidentalpoisoning made up the largest percentage with 36 unique patients(61%). There were 71 (11%) females compared to 600 (89%) males.The highest represented age group was 45-64 with 342 unique patients(51%). Rates by US Census Region were highest in the Midwestand Northeast (27 and 23 per million unique users, respectively)compared to the West and South (15 and 13 per million uniqueusers, respectively) (Figure 1). Accidental CO poisonings showed aseasonal pattern with peaks occurring in late fall, winter, and earlyspring months (Figure 2). CO poisonings classified as unspecifiedhad a similar but less pronounced pattern, while those classified asself-harm were too few to observe any pattern over time. COHb bloodlevels≥10% were present in 111 (17%) of patients with CO poisoningcodes. Of patients with COHb measures≥10%, those with self-harmclassification were least represented with only 7 unique patients (6%).Accidental and unspecified classifications were equally representedwith 53 (48%) and 51 (46%) unique patients, respectively.ConclusionsThe impact of CO poisoning on the VHA patient population hasnot been well studied. The geographic distribution of the majorityof cases in the Midwest and Northeast, and the seasonal distributionof accidental cases in colder months seems to be appropriate withrespect to what is known of unintentional CO poisoning as oftenassociated with heat-generating sources3. Opportunities for furtherinvestigation include how potential CO poisoning cases are evaluatedin VHA given the low percentage of cases with COHb blood levelmeasurements.

Root Causes of Falls in Veterans With Dementia: Opportunity for Intervention in Patient Safety Improvement—A Retrospective Review

2021 ◽  
Vol 75 (Supplement_2) ◽  
pp. 7512510267p1-7512510267p1
Author(s):  
Elizabeth Rhodus ◽  
Elizabeth Lancaster ◽  
Mary Duke ◽  
Andrew Harris
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Health Care Systems ◽  
Veterans Health ◽  
Health Administration ◽  
Root Cause ◽  
Safety Improvement ◽  
Care Systems ◽  
Improve Patient ◽  
Patient Safety Improvement

Abstract Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. The presented research offers an introduction to the use of root-cause analyses in the Veterans Health Administration for identification of falls in veterans with dementia who were referred to or receiving OT. Results identify specific areas for improvement that may be immediately implemented by OTin all health care systems. Such improvements to care may drastically improve patient safety and decrease fall risk in older adults with dementia. Primary Author and Speaker: Elizabeth Rhodus Contributing Authors: Elizabeth Lancaster, Mary Duke, and Andrew Harris

scholarly journals Firearm Injury Encounters in the Veterans Health Administration (VHA), 2010-2015

2017 ◽  
Vol 9 (1) ◽  
Author(s):  
Cynthia Lucero-Obusan ◽  
Aaron Wendelboe ◽  
Patricia Schirmer ◽  
Gina Oda ◽  
Mark Holodniy
Keyword(s):  
Public Health ◽  
Admission Rate ◽  
Time Frame ◽  
Health Concern ◽  
Inpatient Setting ◽  
Veterans Health ◽  
Health Administration ◽  
Firearm Injury ◽  
Number Of Patients ◽  
Vietnam Era

IntroductionFirearm violence is an issue of public health concern leading tomore than 30,000 deaths and 80,000 nonfatal injuries in the UnitedStates annually.1To date, firearm-related studies among Veteranshave focused primarily on suicide and attempted suicide.2-5Herein,we examine firearm violence among VHA enrollees for all manners/intents, including assault, unintentional, self-inflicted, undeterminedand other firearm-related injury encounters in both the inpatient andoutpatient settings.MethodsInpatient and Outpatient encounters with one or more ICD-9-CM firearm external-cause-of-injury codes (E-codes) from1/1/2010-9/30/2015 were extracted from the VHA’s Praedico™Public Health Surveillance System, including demographics, era ofservice/eligibility, encounter type, and deaths. Firearm E-codes wereclassified for manner/intent based on the CDC’s Web-based InjuryStatistics Query and Reporting System (WISQARS™) matrix.6Outpatient/emergency department (ED) data were exclusively fromVHA facilities (a single pediatric patient seen as a humanitarianemergency was excluded from the dataset). Inpatient data includedVHA facilities and some records received from non-VHA facilities.VHA rate of hospitalization for firearm-related admissions wascalculated using the total VHA acute-care admissions for the sametime period as the denominator.ResultsDuring the time frame examined, 5,205 unique individuals wereseen with a firearm E-code. Of these, 4,221 were seen in the outpatient/ED setting only, 597 in the inpatient setting only, and the remaining387 had encounters in both the outpatient/ED and inpatient settings.VHA firearm admission rate was 1.63 per 10,000 VHA admissions,compared to a national rate of 1.96 per 10,000 in 2010.7Table 1 showsthe breakdown of encounters by manner/intent. Unintentional was themost common firearm injury manner/intent. Overall, the median age atinitial encounter was 54 (range 19-100 years), and 96% were male. Thehighest percentage served in the Persian Gulf War Era (2,136, 41%),followed by Vietnam Era (1,816, 35%) and Post-Vietnam Era (716,14%). The greatest number of patients with a firearm-coded encounterresided in Texas (453), California (349), Florida (326), Arizona (214)and Ohio (212).ConclusionsUnintentional injuries were the most common form of firearminjury among VHA enrollees, representing over half of alloutpatient/ED firearm encounters and more than twice the numberof firearm hospitalizations compared with any other manner/intent.Limitations include that not all U.S. Veterans are VHA enrollees;miscoding and misclassification of firearm-related injuries may haveoccurred; and data from non-VHA outpatient/ED encounters andsome non-VHA hospitalizations are not available to our surveillancesystem for analysis. Additional study is needed to further understandthe epidemiology of firearm-related injuries among Veterans andinform VHA leadership and providers

Root Cause Analysis of Reported Patient Falls inORs in the Veterans Health Administration

AORN Journal ◽  
2018 ◽  
Vol 108 (4) ◽  
pp. 386-397 ◽  
Author(s):  
Christina M. Soncrant ◽  
Lisa J. Warner ◽  
Julia Neily ◽  
Douglas E. Paull ◽  
Lisa Mazzia ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Cause Analysis ◽  
Patient Falls ◽  
Root Cause
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