Department of Veterans Affairs patient safety program.

The Department of Veterans Affairs (VA) has been recognized for its patient safety initiatives. In 1998, a separate entity entitled the National Center for Patient Safety (NCPS) was established to promulgate and nurture the patient safety activities throughout the health care facilities of the VA. On the basis of a nonpunitive approach, NCPS fosters a culture of safety whereby clinicians report unsafe situations and close calls without fear of reprisals. The VA patient safety program stresses that reducing iatrogenic injury is best served through an examination of system and process vulnerabilities, with a focus on why something occurred rather than who is at fault. This article discusses the genesis of the VA patient safety program and reviews some of its successes.