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Office of Public and Intergovernmental Affairs


Nation's First Patient Safety Centers Will Benefit Millions

March 4, 1999


Washington, D.C. -- Taking a groundbreaking step that should have substantial ramifications for American health care, Secretary of Veterans Affairs (VA) Togo D. West Jr. today announced the establishment of four Patient Safety Centers of Inquiry and committed $6 million to support the innovative centers over the next three years. The centers are the first of their type in the U.S.

"The health-care industry must begin to view itself as an inherently risky enterprise and adapt systemic error-reducing strategies used in such industries as aviation, nuclear power and military operations," VA Under Secretary for Health Dr. Kenneth W. Kizer said. "Our approach with these Patient Safety Centers of Inquiry is based on principles of continuous learning and quality improvement that has proven highly effective in other industries. We view these centers as learning laboratories that will facilitate cross-industry knowledge and technology transfer," he added.

In addition to researching new knowledge in this area, the centers will focus on disseminating existing knowledge that can be immediately used.

The four VA centers, which will work with universities or other public and private partners in their areas, are:

  • The VA Palo Alto (Calif.) Health Care System.
  • VA's Health Care System of Ohio, Cincinnati.
  • The New England Healthcare System/White River Junction (Vt.)
  • The Tampa (Fla.) VA Medical Center.

Although the extent of the patient safety problem has not been adequately measured, a variety of studies from the private sector indicate that approximately 5 to 15 percent of hospitalized patients are injured during the course of their medical treatment.

Some studies have shown that such injuries affect more than 30 percent of patients. About a quarter of these injuries appear to be serious or fatal. The famous Harvard Medical Practice Study found that 69 percent of physician-caused injuries were preventable.

VA projects that the models of care the centers will propagate and export should result in systematic improvements that will improve health care everywhere, especially in areas such as medication errors and adverse drug events, wrong site surgery, transfusion reactions, restraint-related injuries, falls, burns, pressure ulcers and suicide.

The four new Patient Safety Centers of Inquiry were each awarded approximately $500,000 per year following a nationwide competition among VA medical facilities.



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