Healthcare Inspection Evaluation of the Veterans Health Administration’s National Patient Safety Program

The evaluation was conducted to determine whether the Veterans Health Administration’s (VHA’s) National Patient Safety (NPS) Program has been effective in accomplishing its stated goal of preventing inadvertent harm to patients receiving VHA care and has provided efficient and effective coordination, oversight, and continuous improvement. We concluded that VHA took important, positive steps in 1998 when it expanded existing patient safety activities and created the National Center for Patient Safety (NCPS). VHA’s NPS Program has been the foundation for many national and international patient safety initiatives. We noted several opportunities to strengthen the NPS Program’s effectiveness, oversight, and continuous improvement. To improve operations, we recommended that: All relevant patient data sources be assessed for patient safety significance, coordinated across VHA’s quality and safety programs, and used to drive change. Organized, coordinated oversight of the NPS Program is systematically provided by either the NCPS or another VHA entity. VHA develops a plan to systematically review all aspects of the NPS Program for efficiency and effectiveness and makes revisions as appropriate.