Linda Connell is an experienced pilot and registered nurse, who now leads a pioneering national effort to make healthcare safer. The effort is the Patient Safety Reporting System, initiated by an agreement between the VA and the National Aeronautics and Space Administration (NASA).

The goal is to involve front-line VA employees in contributing reports of safety events and situations from their workplace directly to NASA as an outside agency.

NASA was chosen due to its long and successful history in administering the Aviation Safety Reporting System (ASRS). Linda notes: “NASA has 26 years in aviation safety reporting, providing strong confidentiality protections. Our experience in the aviation environment proves that the concept of reports sent to an external agency works well.”

Key features of PSRS are that it is voluntary, confidential, and non-punitive. NASA removes all names and location information from each report submission to protect the confidentiality of the reporter. Linda invites everyone working in VA facilities including physician, nursing, laboratory, radiology, pharmacy, rehabilitation, dietary, and support staff to report any events or concerns that involve patient safety. “What you consider to be safety is safety to PSRS,” according to Linda.

Now that PSRS has been rolled out, it is receiving reports from VA employees across the country. Linda summarized her invitation: “PSRS is looking forward to your report. Remember... See it, Report it, Make a difference.”

January 2002 Workshop A Success

NASA Ames Research Center at Moffett Field, California, welcomed 286 VA employees from 140 facilities, for a series of one-day PSRS workshops in January. All VISNs were represented; 59% were from Patient Safety or Quality Management, 35% represented Unions, and 6% were physicians and/or administrators.

PSRS Director Linda Connell described the features of the Patient Safety Reporting System, operated by NASA. Rodney Williams of the National Center for Patient Safety spoke about the complementary nature of PSRS and the VA's incident report and Root Cause Analysis (RCA) processes.

Many of the participant's evaluations were enthusiastic:

• “Commitment to confidentiality is clearly paramount to the success of this program.”
• “This program is needed and has been needed for a long time. I have over 30 years Nursing experience and PSRS is long overdue.”
• “I am extremely supportive of PSRS. I see it as an additional source of information that will help us to improve our safety environment.”
• “This is a way to get someone to listen to issues that get reported but never get dealt with or addressed.”
• “I hope VA's success is like NASA's.”

Reports from VA Front-Line Employees

No Drugs... Just Gingko

Self-prescribed remedies are seldom considered by patients to be medications. As a result, an estimated 70% of patients do not reveal herbal use to their health care providers, (Am Surg 2001 Jan).

Since several herbals have been associated with bleeding, including gingko biloba, garlic, feverfew, ginger and ginseng, oversight can be problematic, as described here:

• "We have a large number of patients on anticoagulants. Every few days we find that the PT [Prothrombin Time] (INR) has gone markedly out of the normal therapeutic range. This is often caused by interacting medications or herbals. A large number of adverse outcomes are due to bleeding on anticoagulants. (3 - 5% of patients on Warfarin have bleeding.) There is a warning in CPRS (VA computer system) but it appears to be inadequate or overridden. Need better prevention of risk."

Numerous similar incidents happen almost weekly, according to the PSRS reporter. This report points out the need to specifically detail use of herbals as well as all OTC meds in patients' medical history.

Saved by a Repeat CBC

Checking lab results inconsistent with a patient's condition is essential. This reporter describes what followed when a patient's ER lab tests showed a dramatically low blood count:

• "Patient had significant changes in CBC in only 5 days... [lab values given] ... I questioned whether it was a diluted sample... Patient denied any extreme fatigue, lightedheadedness, etc. Nurse reported that CBC was not recent. Patient was typed and crossmatched for 4 units and plan was to immediately transfuse. Patient arrived at MICU. Repeat labs sent."

Good catch. Repeat lab values were unchanged from 5 days earlier. The conclusion:

• "Patient discharged to home, approximately one hour after arrival to MICU (after admitted!). Transfusion not given."

Looks Can Be Deceiving

This reporter tells of a serious “near miss”:

• "Order for metronidazole 500 mg IVPB. Dispensed KCl 20 mEq IVPB. Although the bags are slightly different in size, both products (manufactured by same company) are strikingly similar in appearance. While investigating this event, discovered 6 additional KCl IVPB's in the metronidazole storage bin. I assume this means more than one person made the same mistake."

This reporter's diligence prevented six potential adverse events.