Circulation 60,475 • Volume 14, No. 1 • Spring 1999

VA System Sets up 4 Patient Safety Centers of Inquiry

David M. Gaba, M.D.

Anesthesiologists Figure Prominently

The Department of Veterans Affairs recently announced the funding of four Patient Safety Centers of Inquiry. These Centers will focus on research and education regarding a variety of aspects of patient safety. Interestingly, anesthesiologists figure prominently in at least two of the Centers. At the time of this writing the details of all the Centers’ structure and planned activities have not been released so this article is limited to that of the author’s Patient Safety Center of Inquiry (PSCI) at VA Palo Alto HCS and the Midwest Patient Safety Center of Inquiry in Cincinnati, Ohio.

Patient Safety Center of Inquiry at VA Palo Alto HCS

Based in the Bay Area of California is the Patient Safety Center of Inquiry (PSCI) at VA Palo Alto. This Center is funded for three years at approximately $500,000 per year. It consists of three faculty (all of whom are anesthesiologists) and additional professional personnel, supported by Center administrative and technical staff. The Center is directed by Dr. David Gaba, a staff anesthesiologist at VA Palo Alto and associate professor of anesthesia at Stanford University. Dr. Gaba’s laboratory has a long history of work in patient safety, which in fact was initiated with funding from the Anesthesia Patient Safety Foundation. In addition to its internal collaborators within the VA Palo Alto HCS and Veterans Health Administration (VHA) Veterans Integrated Services Network (VISN) 21, external collaborators include: UCSF Stanford Health Care, The Center for Health Policy at Stanford University, and the California Collaboration for Improving Patient Safety. The Center’s activities will be overseen by a distinguished National Advisory Board, whose members include Dr. Ellison C. Pierce, Jr., Executive Director of the APSF, and Dr. Jeff Cooper, a member of the Executive Committee of the APSF.

The PSCI at VA Palo Alto will address five issue areas:

* Theory of Organizational Safety Applied to Health Care. This area will be directed by Dr. Gaba and will deal with the theoretical understanding of how patient safety is fostered or is thwarted by the organizational structures and processes of modern health care.

* Simulation-Based Training in Decision Making, Crisis Management, and Teamwork. This area will be directed by Dr. Brian Smith, also an anesthesiologist at VA Palo Alto and Stanford University. This section will continue work by the VA/Stanford group on extending simulation based training from anesthesiology into other medical domains including “code teams” and intensive care units. A later project in conjunction with the “Cultures of Safety in Health Care” area will be conducting simulation-based training of senior management personnel and quality managers concerning the response to catastrophic adverse clinical events. In addition to providing hands-on practice and debriefing in organizational learning from accidents or near-misses, these simulations will help to inoculate key executives with a gut understanding of the importance of organizational safety in the hospital setting.

* Effects of Sleep Deprivation and Fatigue on Patient Safety. This area will be directed by Dr. Steven Howard, an anesthesiologist at VA Palo Alto and Stanford University. Dr. Howard’s pioneering work on fatigue and sleep deprivation of clinical personnel was initially funded by the Anesthesia Patient Safety Foundation and Drs. Howard and Gaba produced a videotape on this topic in the ASA Patient Safety Videotape series. This section of the PSCI will assess the effects of fatigue on daytime sleepiness of different types of clinicians (residents, experienced physicians, and nurses) and of individuals of different ages.

In addition, the section will develop educational curricula to assist health care workers to manage their sleep/wake status for optimal patient (and personal) safety. Finally, this section will develop techniques to assist in determining the contribution of sleep deprivation to the occurrence of adverse patient outcomes.

* Cultures of Safety in Health Care. This area will be codirected by Dr. Gaba and quality management personnel from VHA VISN 21.

Among other activities, this section will develop and administer instruments measuring organizational and work group cultures and processes related to organizational safety, and learning. The influence of production pressure on personnel in many health care domains will also be measured.

* Safety-Related Event Reporting and Analysis. This area will be jointly directed by Drs. Gaba, Howard, and Smith, along with personnel from the external collaborating institutions. This section will design and implement systems of event reporting and analysis, especially those analogous to the NASA Aviation Safety Reporting System. It is possible that the Center of Inquiry will become responsible for the establishment and operation of the report analysis and feedback unit of the planned VHA national pilot project on patient safety reporting systems.

Midwest Patient Safety Center of Inquiry

Based at the VA’s Health Care System of Ohio, Cincinnati is the Midwest Patient Safety Center, directed by Dr. Marta L. Render. This Center has David Woods, PhD and Richard Cook, MD (an anesthesiologist at University of Chicago) as Associate Directors. Drs. Woods and Cook are also former recipients of a research grant from the APSF. This Center will be centered around the theme of GAPS (Getting at patient safety) in the continuity of care. The main target of the Midwest Center’s inquiry is (1) where and how gaps arise, (2) how people cope with gaps and (3) how proposed and predicted change in the system can be assessed in terms of its likely effect on gaps, (4) how to assess approaches intended to reduce gaps, and (5) how to help practitioners struggle with gaps.

Additional Centers

Additional Centers of Inquiry have been established at The New England Healthcare System/White River Junction (Vt.) and the Tampa (Fla.) VA Medical Center. Collectively, the Patient Centers of Inquiry hope to become major foci for patient safety activities, both within the VHA and in the nation as a whole.

Additional information may be found in the text of the March 4, 1999, press release on the Patient Safety Centers of Inquiry which is reprinted below.


Washington, D.C. Taking a groundbreaking step that should have substantial ramifications for American health care, Secretary of Veterans Affairs (VA) Togo D. West Jr. today announced the establishment of four Patient Safety Centers of Inquiry and committed $6 million to support the innovative centers over the next three years. The centers are the first of their type in the U.S. “The healthcare industry must begin to view itself as an inherently risky enterprise and adapt systemic error-reducing strategies used in such industries as aviation, nuclear power and military operations,” VA Under Secretary for Health Dr. Kenneth W. Kizer said. “Our approach with these Patient Safety Centers of Inquiry is based on principles of continuous learning and quality improvement that has proven highly effective in other industries. We view these centers as learning laboratories that will facilitate cross-industry knowledge and technology transfer,” he added.

In addition to researching new knowledge in this area, the centers will focus on disseminating existing knowledge that can be immediately used.

The four VA centers, which will work with universities or other public and private partners in their areas, are:

* The VA Palo Alto (Calif.) Health Care System.

* VA’s Health Care System of Ohio, Cincinnati.

* The New England Healthcare System/White River Junction (Vt.)

* The Tampa (Fla.) VA Medical Center.

Although the extent of the patient safety problem has not been adequately measured, a variety of studies from the private sector indicate that approximately 5 to 15 percent of hospitalized patients are injured during the course of their medical treatment.

Some studies have shown that such injuries affect more than 30 percent of patients. About a quarter of these injuries appear to be serious or fatal. The famous Harvard Medical Practice Study found that 69 percent of physician-caused injuries were preventable.

The VA projects that the models of care the centers will propagate and export should result in systematic improvements that will improve health care everywhere, especially in areas such as medication errors and adverse drug events, wrong site surgery, transfusion reactions, restraint-related injuries, falls, burns, pressure ulcers and suicide.

The four new Patient Safety Centers of Inquiry were each awarded approximately $500,000 per year following a nationwide competition among VA medical facilities.

Dr. Gaba, Veterans Affairs Palo Alto Health Care System and Department of Anesthesia, Stanford University, Palo Alto, CA, is Secretary of the APSF.