Please see Alerts, Topics in Patient Safety (TIPS) Newsletters, and view PowerPoint: Information on Research Databases for additional information.
Hazard Summaries | Healthcare Failure Mode and Effect Analysis | Falls Toolkit | Ensuring Correct Surgery | Hand Hygiene | PSAT | Mental Health Environment of Care Checklist
Oxygen (Compressed Gas) Cylinder Hazard Summary
- The Basics of Healthcare Failure Mode and Effect Analysis (PDF) (Word)
- HFMEA Power Point Presentation
- Instructional Materials to Accompany the HFMEA Videotape (PDF) - Complete booklet for use with videotape. (10.5 MB)
- HFMEA Worksheets (Word)
- HFMEA Worksheet, Steps 4 & 5 (Excel)
- © Joseph DeRosier, PE, CSP; Erik Stalhandske, MPP, MHSA; James P. Bagian, MD, PE; Tina Nudell, MS: Using Health Care Failure Mode and Effect Analysis: The VA National Center for Patient Safety's Prospective Risk Analysis System. (PDF) (HTML)The Joint Commission Journal on Quality Improvement Volume 27 Number 5:248-267, 2002. Posted with permission.
- Joint Commission Executive Briefings on the Patient Safety Standards: Designing Safer Health Care Systems. 2001. Joint Commission Resources, pp 92-95.
- McDermott, Robin E., Raymond J. Mikulak, and Michael R. Beauregard. 1996. The Basics of FMEA. Portland, OR: Resources Engineering, Inc.
- Stamatis, D.H. 1995. Failure Mode and Effect Analysis: FMEA from Theory to Execution. Milwaukee, WI: ASQ Quality Press.
- The Patient Safety Improvement Handbook, 2001. VHA National Center for Patient Safety. Ann Arbor, MI.
- ISMP Sample Case for PCA Pump (Word)
- Erik Stalhandske, MPP, MHSA; Joseph DeRosier, PE, CSP; Ryan Wilson, MS; Joe Murphy, APR, MS: Healthcare FMEA in the Veterans Health Administration (PDF). Patient Safety & Quality Healthcare, Volume 6, Issue 5: 30-33, 2009. Posted with permission.
Many facilities are working to find ways to reduce the number of falls as well as the severity of the falls that do occur.
In an effort to help facilities, we created the Falls Toolkit.
VHA Directive 2004-028: Ensuring Correct Surgery and Invasive Procedures
- Directive 2004-028(PDF) (Word)
- Ensuring Correct Surgery Poster (PDF) (Word)
- Summary of Changes/Updates in Directive 2004-028 (Word)
- Two Basic Questions about Directive 2004-028 (Word)
- Frequently Asked Questions
- Course evaluation and certificate of attendance. Enrollment instructions and link to the EES Registration Web site.
Hand Hygiene Information and Tools - a collection of reference documents and tools to help health care providers and others to understand and respond appropriately to: The CDC Guideline on Hand Hygiene in Health Care Settings; the Joint Commission National Patient Safety Goal on Preventing Nosocomial Infections; and the VHA Directive on Hand Hygiene Practices.
Hand Hygiene Information and Tools: Frequently Asked Questions
The Patient Safety Assessment Tool (Excel) (PSAT) - a cognitive aid to assist managers and staff conduct an objective assessment of a patient safety program. The tool covers program administration and management and provides walk-around sections focusing on the patient care environment.
The Mental Health Environment of Care Checklist (XLS, 225KB) (MHEOCC) was developed for Veterans Affairs Hospitals to use to review inpatient mental health units for environmental hazards. The purpose is to identify and abate environmental hazards that could increase the chance of patient suicide or self-harm. The checklist has been used in all VA mental health units since October 2007. Contact Peter.Mills@va.gov for more information.