VA, NASA to develop no-penalty error reporting
System designed to reduce fear of reprisal
In an effort to recreate for health care what is hailed as a strong point of the aviation industry, senior officials of the Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) have signed an agreement to create a system to report health care errors and close calls in VA health care facilities. The system is intended to create an environment in which health care workers are more comfortable reporting incidents without fearing punishment.
The agreement commits the two agencies to create a voluntary external patient safety reporting system for the VA. That reporting system will be operated by NASA and modeled after the Aviation Safety Reporting System (ASRS), which NASA operates for the Federal Aviation Administration.
Thomas Garthwaite, MD, the VA’s acting undersecretary for health, signed the agreement on behalf of the VA. Henry McDonald, MD, director of NASA’s Ames Research Center at Moffett Field, CA, signed on behalf of the space agency. Ames Research Center will operate the VA Patient Safety Reporting System.
"We will use our experience operating the Aviation Safety Reporting System to develop VA’s Patient Safety Reporting System," says McDonald. "I am confident that the new system — which will use data reported by health care providers in the front line of patient safety — will enable VA to set new standards for patient safety and further improve the quality of health care in this country."
The VA operates 172 medical centers across the country and last year had more than 3 million patients enrolled in its health care system. In 1997, VA began consolidating its longstanding patient safety programs and, in 1998, created the National Center for Patient Safety.
Ames Research Center is NASA’s lead center for Information Technology, Aviation Capacity and Aerospace Operation Systems. It has operated the ASRS since it was established in 1976. The system collects aviation operation reports submitted from pilots, air traffic controllers, flight attendants, mechanics, and others who are involved in or observe an incident or situation that may compromise aviation safety. All submissions are voluntary and held in strict confidence.
The VA already requires that employees report certain serious errors, but Garthwaite says it is widely known in the health care community that many incidents go unreported because people are afraid they will be punished for their involvement. That secrecy is particularly frustrating with near misses, he says, because the incident could be used as a learning experience so that a patient is not harmed in order to make improvements. The aviation industry relies on a program that allows pilots to report near misses without being held personally responsible.
Under the planned VA program, health care workers can report medical mistakes they make or witness. After questioning the health care worker for more details, NASA will strip all identifiers from the report so there can be no personal repercussions. The information will be analyzed by medical experts hired by NASA to determine how the incident occurred and what might be learned from it.
The similar aviation safety system, run by NASA for the Federal Aviation Administration, receives 35,000 reports a year.
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