Improving Patient Safety through Educational Initiatives

摘要

The VA National Center for Patient Safety (NCPS) came into being just prior topublication of the IOM Report (Kohn, 1999). From the outset, the approach used byNCPS 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 professionalrole, a Patient Safety Manager, employed at every VA hospital [Bagian, 2002]. A secondeffort, detailed here, is specifically focused on filling a patient safety leadership gap.Clinician-leaders become patient safety leaders as they acquire knowledge and skills inteamwork, communication, and other HFE-based methods for problem-solving.