VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities

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Description

A chapter report issued by the Government Accountability Office with an abstract that begins "The Department of Veterans Affairs (VA) introduced its Patient Safety Program in 1999 in order to discover and fix system flaws that could harm patients. The Program process relies on staff reports of close calls and adverse events. GAO found that achieving success requires a cultural shift from fear of punishment for reporting close calls and adverse events to mutual trust and comfort in reporting them. GAO used ethnographic techniques to study the Patient Safety Program from the perspective of direct care clinicians at four VA ... continued below

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United States. Government Accountability Office. December 15, 2004.

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Description

A chapter report issued by the Government Accountability Office with an abstract that begins "The Department of Veterans Affairs (VA) introduced its Patient Safety Program in 1999 in order to discover and fix system flaws that could harm patients. The Program process relies on staff reports of close calls and adverse events. GAO found that achieving success requires a cultural shift from fear of punishment for reporting close calls and adverse events to mutual trust and comfort in reporting them. GAO used ethnographic techniques to study the Patient Safety Program from the perspective of direct care clinicians at four VA medical facilities. This approach recognizes that what people say, do, and believe reflects a shared culture. The focus included (1) the status of VA's efforts to implement the Program, (2) the extent to which a culture exists that supports the Program, and (3) practices that promote patient safety. GAO combined more traditional survey methods with those from ethnography, including in-depth interviews and observation."

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Government Accountability Office Reports

The U.S. Government Accountability Office (GAO) is an independent, nonpartisan agency that works for the U.S. Congress investigating how the federal government spends taxpayers' money. Its goal is to increase accountability and improve the performance of the federal government. The Government Accountability Office Reports Collection consists of over 13,000 documents on a variety of topics ranging from fiscal issues to international affairs.

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  • December 15, 2004

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  • June 11, 2014, 5:03 a.m.

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United States. Government Accountability Office. VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities, report, December 15, 2004; Washington D.C.. (digital.library.unt.edu/ark:/67531/metadc292102/: accessed October 21, 2018), University of North Texas Libraries, Digital Library, digital.library.unt.edu; crediting UNT Libraries Government Documents Department.