James P. Bagian

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BACKGROUND The patient safety program in the Department of Veterans Affairs (VA) began in 1998, when the National Center for Patient Safety (NCPS) was established to lead the effort on a day-to-day basis. NCPS provides the structure, training, and tools, and VA facilities provide front-line expertise, feedback about the process, and root cause analysis(More)
OBJECTIVE To describe incorrect surgical procedures reported from Veterans Health Administration (VHA) Medical Centers from 2001 to mid-2006 and provide proposed solutions for preventing such events. DESIGN Descriptive study. SETTING Veterans Health Administration Medical Centers. PARTICIPANTS Veterans of the US Armed Forces. INTERVENTIONS The VHA(More)
BACKGROUND The Veterans Administration (VA) identified patient safety as a high-priority issue in 1997 and implemented the Patient Safety Improvement (PSI) initiative throughout its entire health care system. In spring 1998 the External Panel on Patient Safety System Design recommended alternative methods to enhance reporting and thereby improve patient(More)
Spaceflight induces a cephalad redistribution of fluid volume and blood flow within the human body, and space motion sickness, which is a problem during the first few days of spaceflight, could be related to these changes in fluid status and in blood flow of the cerebrum and vestibular system. To evaluate possible changes in cerebral blood flow during(More)
BACKGROUND Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS). METHODS The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew(More)
The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties and its member boards introduced the six domains of physician competency in 1999. This initiated a national dialogue concerning the elements of competency of the physician, and incorporation of these elements into the framework of evaluation of(More)
of “Roadmap for Provision of Safer<lb>Healthcare Information Systems: Preventing e-<lb>Iatrogenesis” Joan S. Ash, Ph.D., M.L.S., M.B.A.; Charles M. Kilo, M.D., M.P.H.; Michael Shapiro, M.A.,<lb>M.S.; Joseph Wasserman, B.A.; Carmit McMullen, Ph.D.; William Hersh, M.D. BACKGROUND AND METHODS e-Iatrogenesis, defined as “patient harm caused at least in part by(More)
BACKGROUND In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools,(More)
OBJECTIVE To determine whether there is an association between the Veterans Health Administration Medical Team Training (MTT) program and surgical morbidity. DESIGN, SETTING, AND PARTICIPANTS A retrospective health services study was conducted with a contemporaneous control group. Outcome data were obtained from the Veterans Health Administration Surgical(More)