Developing a culture of safety in the Veterans Health Administration.

CONTEXT: Weaving patient safety into the fabric of clinical activities is an increasingly important aspect of medical care.
OBJECTIVE: To detail the steps taken by the Veterans Health Administration (VHA) to integrate patient safety into its organizational structure.
DESIGN: Descriptive study.
SETTING: VHA. DATA SOURCES: VHA documents, congressional testimony, the medical literature, the general press, and personal communications.
RESULTS: The VHA leadership has taken steps to promote a culture of safety by making public commitments to improving patient safety, allocating resources toward establishment of special centers, enhancing employee education on patient safety, and providing incentives to promote safety. The VHA is also establishing one mandatory and one voluntary adverse event reporting system; in the latter case, the reporter remains anonymous. Examples of nationally mandated initiatives are bar coding of all medications and use of computerized medical record that includes order entry, laboratory and imaging results, and all encounter notes.
CONCLUSIONS: The VHA's initial efforts may serve as a template for other health care organizations that wish to engineer a culture of safety. Although progress has been made, patient safety efforts require constant attention to guard against becoming a new bureaucracy or simply window dressing.