Developing a culture of patient safety at the VA.

Patient safety is a topic that has become prominent in the minds of many, both within and outside the healthcare field over the past several months. But in fact, literature in medical journals describing this topic goes back decades. However, studying these issues is only the first step towards developing useful and practical tools to address errors and does little to change the safety culture that underlies these systems. The VA has taken several steps towards a safety culture and the development and implementation of tools, such as: 1) error reporting mechanisms; 2) tools for root cause and corrective action; and 3) management tools (e.g., safety awards).