A Publication of the VA Office of Research & Development, Health Services Research & Development Service,

Management Decision and Research Center, in conjunction with the Academy for Health Services Research

and Health Policy

continued on page 2

Promoting Patient Safety at VA:

Learning from Close Calls

By James P. Bagian, M.D., P.E., Director 

VA National Center for Patient Safety

FORUM

VA HEALTH SERVICES RESEARCH & DEVELOPMENT OCTOBER 2001

Patient safety is a fundamental

tenet of VA care. The goal is to

ensure that patients experience

optimal outcomes — without unintended consequences or side effects

that undermine their health or

security. While patient safety has

always been a priority for VA, during the past few years we have

refocused our approach. We have

shifted the VA’s emphasis from

punishment to prevention, and, in

doing so, have engaged VA health

care professionals who are eager to

provide better and safer care for

their patients.

Patient safety gained a national

spotlight in 1999 with the release

of a landmark report, To Err is

Human: Building a Safer Health

System, by the Institute of

Medicine (IOM). This report

attributed tens of thousands of

hospital deaths per year to medical

error. These figures became the

subject of considerable debate, but

the point was clear: Patient safety,

by any measure, is a substantial

problem that requires immediate

attention. 

Fortunately, VA had a head

start in addressing the issue. More

than two years before the IOM

report, VA established the Patient

Safety Improvement Initiative,

which had at its core an internal

reporting system designed to capture reports of sentinel events,

close calls, and other adverse

events.

After less than a year, it became

obvious that this reporting system

was not identifying VA’s vulnerabilities and necessary preventive

actions as well as had been hoped.

In 1998, VA convened the Expert

Advisory Panel for Patient Safety

System Design and charged it with

the task of finding ways for VA to

better identify system-level vulnerabilities and use this information

to reduce or eliminate these vulnerabilities. 

Learning from Close Calls

Perhaps most importantly, the

Panel concluded that reports alone

do not improve patient care. The

actions we take based on what we

glean from reports are what make

a difference. The Panel also identified the importance of looking at

“close calls” — events or situations

that could have resulted in accidents, injuries or illnesses, but did

not, either by chance or through

timely intervention. Close calls are

important because they present

opportunities to learn without the

pain of an actual mistake. 

Consider this example: Mr.

Jones is admitted to a VA hospital

to have an arthroscopy on his right

knee. Hospital staff prep and

drape his left knee. Fortunately,

someone catches the mistake and

Mr. Jones receives the correct proC DIRECTOR’S LETTER OMMENTARY

As FORUM goes to press, the nation

mourns for the victims of the tragic

events of Sept. 11. We know that our

country will respond and that the

brave men and women of our military will be called upon to serve.

They will be tomorrow’s veterans.

For all of us within VA, it is our honor

and privilege every day to serve

America’s veterans and their families

with dignity and compassion. Through

our work, we too serve America. 

Enhancing our capacity for this

work, I am pleased to announce

several new HSR&D Centers: the

Rehabilitation Outcomes Research

Center for Veterans with Central

Nervous System Damage at the North

Florida/South Georgia VAMC, which

is the first Center jointly funded by

HSR&D and the Rehabilitation

Research Service; the Center for

Health Equities Research and

Promotion, affiliated with the

University of Pittsburgh and the

University of Pennsylvania; and a

new QUERI Coordinating Center

based at the Minneapolis VAMC

that will focus on colorectal cancer. 

In addition, five Research

Enhancement Award Programs

have been funded: ■ Patient Safety:

Safe Mobility for Frail Elderly and

Persons with Disabilities, Tampa VAMC

■ Center for Quality Improvement

Research, Cleveland VAMC 

■ Program for Interdisciplinary

Research in Health Care Organization, Iowa VAMC ■ Information

Management for Patient-Centered

Treatment, Roudebush (Indianapolis)

VAMC ■ Enhancing VA Health

Services Research in Patient

Centered Care, VA San Diego

Healthcare System. 

I believe each of these centers

will make important contributions

to the health care of our veterans.

John G. Demakis, M.D.

Director
2

cedure. Staff may discuss the close

call briefly, but the incident won’t

be investigated or reviewed. Three

months later, this same mistake

actually happens — that is, an

arthroscopy is performed on the

wrong knee of another patient.

The staff members involved discover that their colleagues nearly made

the same mistake with Mr. Jones.

But because Mr. Jones wasn’t

injured, everyone simply breathed a

sigh of relief. The event wasn’t 

recognized as a systems problem —

and a learning opportunity.

Nothing was learned, and the next

patient suffered instead. 

If the staff taking care of Mr.

Jones had taken the time to address

possible system-level issues — such

as appropriate patient and surgical

site identification — raised by their

close call, this second incident could

have been prevented. The lesson is

that close calls offer the best opportunities for learning because they

occur more frequently than sentinel

events, people don’t get hurt, and

staff members can discuss them

more freely than adverse events

where someone actually suffered.

The old saying that experience is

the best teacher has a flip side —

experience is also the most expensive teacher, and our patients bear

the brunt of the cost when we make

a mistake.

The Panel recommended building a patient safety system with

learning — not accountability — as

its core purpose. Accountability

has an important role in any organization, but it is not an effective

way to accomplish learning. 

Commentary

continued from page 1

C OMMENTARY

Prevention, Not Punishment

Accordingly, we focused our efforts

on creating a system that promotes

personal responsibility and professional respect and engages health

care professionals in a cooperative,

participatory learning process

aimed at preventing adverse

events. The approaches we devised

are designed to encourage health

care professionals to report adverse

events and close calls without fear

of reprisal and with the assurance

that the information they report

will be used to improve patient

care. 

We revised the internal reporting system, adding to it a welldefined analysis process with a

number of cognitive aids and computer-assisted tools for preventing

adverse events through systemslevel solutions. We also provided

intensive training and mentoring

throughout the program rollout

and beyond. As a result of these

efforts, the number of close calls

reported has skyrocketed. More

significantly, the solutions developed by analyzing these incidents

have had a tremendous impact —

worldwide in some cases. 

Despite these efforts and results,

it was clear that fear of reprisal

remained a barrier to full reporting. That is why we created a complementary system administered

outside VA.

In May 2000, VA partnered with

the National Aeronautics and

Space Administration (NASA) to

develop a voluntary, external system based on NASA’s highly successful Aviation Safety Reporting

System (ASRS). This collaboration

ultimately resulted in the VANASA Patient Safety Reporting

System (PSRS), which is currently

being rolled out nationwide in the

VA. NASA, acting as an objective

external third party, is responsible

for administering the PSRS, which

has been designed as a completely

confidential reporting system that

permits VA staff to report a range

of incidents without fear of repercussion. This system supplements

the internal system and acts as a

safety valve so that vulnerabilities

that would otherwise go unknown

can be identified. Unlike VA’s

internal system, the PSRS is not

designed to come up with systemslevel solutions but to catch those

otherwise unknowable vulnerabilities. Solutions must be formulated

through activities separate from

those of the PSRS.

Two crucial features of the

PSRS assure staff confidentiality

and promote learning:

■ Confidential Reporting. It is

important to note that reports are

not submitted anonymously

because NASA may follow up with

the reporter to get the most accurate picture possible of the systems-level vulnerability. But

because NASA administers the system for VA, no VA personnel are

involved in the processing, analysis, or handling of these reports

before they are stripped of all identifying information. 

■ Narrative Reporting. Unlike

checklist reports, narrative reporting by users provides more information and permits a richer

understanding of the context in

which the event occurred. This

helps identify system vulnerabilities. 

Reports supply the fuel that

powers VA’s patient safety

improvement effort. If vulnerabilities aren’t recognized, they can’t be

addressed, and it is in mitigating

these flaws that we produce true

value. If we fail to convert the

information we gather from events

reporting into preventive actions,

there is little point in continuing

reporting these events at all.

Next Steps 

Where do we go from here? Within

the next year, we are embarking on

several exciting initiatives, including the Failure Modes and Effects

Analysis (FMEA), aggregated

reviews, and national Root Cause

Analysis (RCA) software rollout.

These activities get us into prospecC lose calls present

opportunities to learn

without the pain of an

actual mistake. 

continued on page 8
3

R ESPONSE TO COMMENTARY

VA’s Approach To Ensuring Patient Safety 

Is Responsible — and Realistic

By Rodney A. Hayward, M.D., HSR&D Center of Excellence, Ann Arbor

Ensuring patient safety is an ethical and moral obligation for all

health care providers and organizations. Although some statistics

about the number of deaths due to

medical errors are undoubtedly

exaggerated, no one should doubt

that the problem is very real. 

Efforts to ensure and improve

patient safety are still in their

early stages. Among the questions

yet to be fully answered: What are

the definition and scope of patient

safety? How should patient safety

initiatives interface and overlap

with quality monitoring and

improvement? What is the best

way to implement a coordinated

patient safety program? 

To remain a leader in patient

safety, the VA is continuing to

refine its approach to safety monitoring and to learn from its early

experiences. Most importantly, it

is adapting its methods based on

what appears to work best. For

example, the VA National Center

for Patient Safety is currently

soliciting information on “close

calls,” rigorously evaluating safety

concerns, and seeking out research

partnerships with HSR&D. These

developments reflect the VA’s

emphasis on understanding the

nature of serious safety problems

and on the need to carefully evaluate the merits of proposals

designed to decrease preventable

adverse events.

At the same time, we must be

cognizant of the difficulties and

risks involved when intervening in

a complex system like medical care.

It is much easier to identify problems with the current approach

than it is to design a better system.

We must carefully consider

whether a proposed system or policy change will truly decrease the

risk of patient harm — without

excessive costs, complexity, disruption, and, most importantly, without creating new problems that

may be worse than the original

problem. 

Defining Feasible Goals

Analogies frequently are drawn

between patient safety and air traffic safety. In some cases, where the

error under question is egregious

or catastrophic, these analogies are

on target. For example, we must

try to reduce to zero instances of

amputating the wrong leg or

administering a fatal dose of medication. These represent the type

of rare but unacceptable events

sometimes encountered in air

transportation safety. 

However, many of the safety

problems that we face in medicine

are more analogous to ground

transportation safety. Although

preventable adverse events are common, it is unrealistic to think that

they can be eliminated completely.

Yes, setting the speed limit to 5

miles per hour could probably prevent most motor vehicle deaths, but

that solution is simply not feasible.

Similarly, some of the most common safety problems found in large

medical studies can be substantially reduced, but they cannot feasibly

be eliminated. Most studies evaluating patient safety have identified

patient vulnerabilities related

either to very high-volume practices or complex issues that could

make pursuit of zero errors virtually impossible and even counterproductive. Common problems that

lead to preventable mortality and

morbidity include delays in medication dispensing, confusion during

cross-coverage of patients, decisions involving patient transfer or

discharge, diagnosis, and choice of

treatment. To address these types

of complex problems, collaboration

and coordination among the

National Center for Patient Safety,

the Office of Quality & Performance,

and HSR&D are likely to be very

important. 

The first step toward improving

safety and quality is to recognize

and accept achievable safety goals.

Given the resources that we have

available, we must try to reduce

these problems, but we must also

realize that pharmacists, nurses,

clerks, and physicians are already

working extremely hard, and that

whatever patient safety systems we

develop must consider this fact.

The most effective systems will be

those that make it easier for people

to avoid serious mistakes without

disrupting their busy days. If we

create redundant or reminder systems that make it substantially

harder for health care professionals

to do their jobs, these systems will

probably be ineffective and possibly

even harmful.

The patient safety movement

represents a wonderful opportunity

for us to improve medical care. We

should all be proud of the leadership and innovation that the VA

has provided in this area. However,

participating in patient safety is

everyone’s responsibility. No

patient safety or quality improvement system will work unless we

help foster a culture of quality and

safety. The new emphasis on prevention, rather than on punishment, allows us a better

opportunity to actively help each

other improve health care. No one

should be persecuted for making a

mistake, but each of us has a moral

responsibility to try to make health

care better and safer. 

I t is much easier to

identify problems than it

is to design a better system.
4

R ESEARCH HIGHLIGHT

Using Indicators To Prevent Hospital Medical Errors: 

Case Study Illustrates the Importance of Validation

By Timothy Hofer, M.D., M.Sc., VA Ann Arbor Healthcare System

In order to prevent medical errors,

we must know where we as

providers of health care services are

vulnerable. Indicators for monitoring the delivery of health care services allow us to do that — to see

where there are flaws or problems

in the system and address them

before a patient is hurt. 

Unfortunately, although we have

managed to produce reams of

guidelines and, in some cases, retrospectively explore the reasons for

bad outcomes, we have been less

successful in developing indicators

that alert us to potential process-ofcare problems. There is a simple

explanation for this. In order to

develop a reliable process-of-care

indicator, you need clear, researchbased evidence of a link between

process and outcome. Little such

evidence exists. In addition, there

is a need for more generic indicators that assess quality of care

across diagnoses for some of the

sickest patients seen in hospital 

settings, where the intensity of care

raises the risk of problems in the

process of care. 

Examining Adverse

Outcomes

Our goal in the Laboratory

Abnormalities Project was to develop a set of indicators for efficiently

identifying and monitoring five preventable, hospital-acquired adverse

events. More broadly, we sought to

delineate a general methodology for

developing and validating new indicators of hospital quality of care

and to identify the challenges to

developing indicators for the many

clinical areas where experimental

evidence on relationships between

process and outcome is lacking.1

Our study had three components:

(1) Based on the literature and a

pilot study, we selected adverse

events that could be considered

indicators of poor quality care and

measured how frequently they

occurred. 

(2) An expert panel identified and

ranked the importance of a comprehensive set of specific process measures causally related to the

development of the adverse events.

We then developed a list of key

processes to look for when these

events occurred. 

(3) Using a matched case control

design, we tested the association

between specific processes of care

and specific adverse events.

We selected five hospital-acquired

adverse events where poor monitoring or inattention play key roles:

hypokalemia, hyperkalemia,

hyponatremia, acute renal failure,

and digoxin toxicity. 

Iatrogenic electrolyte disorders

and drug toxicity occur frequently,

at rates ranging from 0.3 percent to

2.8 percent of hospitalizations. The

frequency of these adverse events

increases substantially — fivefold

to fifteenfold — among patients in

the highest quartile of relative

treatment intensity. However,

even controlling for treatment

intensity, less frequent monitoring

of drug or electrolyte levels and

measures suggesting inadequate

response to milder levels of electrolyte disorders were highly predictive of these adverse outcomes. 

A case control study showed that

failure to perform key processes of

care was associated with a twofold

to threefold increase in the rate of

developing an adverse event.

Looking at our results, the process

problems that occur most frequently involve inadequate response to

milder degrees of hyperkalemia and

hypokalemia. This finding suggests

that alerting providers to these

milder events could help prevent

the more serious events. More centralized interventions — like stop

orders for medications and automatic consultation by clinical pharmacists or specialty services —

might also be effective.

Validating Indicators is Key

However, we also found that the

process indicators for prevention of

renal failure were not associated

with hospital-acquired renal failure.

This finding may be even more

instructive because it underscores

the importance of conducting validation studies before disseminating

quality indicators. We identified

several process problems that

appear on clinical grounds and in

the view of a national expert panel

to be critical to the development of

hospital-acquired renal failure. Yet

these problems occurred as frequently in a group of control

patients who did not develop renal

failure in the hospital.2

This example clearly shows that

developing quality indicators may

be a complete waste of time unless

they are validated. At this point,

we still have no evidence that

higher rates of hospital-acquired

renal failure or digoxin toxicity are

associated with more in-hospital

process problems in the management of drugs, fluids, and electrolytes.

continued on page 8

E ffective quality indicators must either directly

measure or be clearly

linked to definable

processes of care.
5

R ESEARCH HIGHLIGHT

Adverse Drug Events: The Harder You Look, the More You Find

By John F. Hurdle, M.D., Ph.D., and Jonathan Nebeker, M.S., M.D., VA Salt Lake City Health Care System

Geriatric Research, Education, and Clinical Center 

Late in 1999, the Institute of

Medicine (IOM) released its now

famous report, To Err is Human.

This document caused an uproar,

focusing physicians, politicians,

and patients alike on the staggering number of medical misadventures that occur routinely in this

country. It underscored with dramatic and convincing data how universally under-appreciated medical

errors were. 

The VA has been consistently

well ahead of the curve on patient

safety, as evidenced by the fact that

fully two years before the IOM

report hit the streets, the VA’s

HSR&D was preparing a call for

proposals on patient safety

research initiatives. 

In response to that call, a team

at the Geriatric Research,

Education, and Clinical Center in

Salt Lake City proposed to mount

an epidemiologic and economic

study of inpatient adverse drug

events (ADEs), in order to characterize the extent of the problem

and to define clinically rational

intervention schemes. 

The research team began with a

thorough literature review of pertinent articles from the past 10 years

(with some exceptions for oftencited articles). This review made it

clear that inpatient ADEs were a

problem; what was not clear was

the extent of the problem. A report

by the U.S. Government

Accounting Office on ADE incidence (GAO/HEHS —00-21) issued

in 2000 is illustrative: It cites articles that determined ADE rates

ranging from 0.56 per 100 admissions to more than 30 per 100. 

There are few clinical syndromes

where the literature routinely

offers a fifty-fold variation in incidence. The research team recognized three confounders that

accounted for this variation: 

1) Little consistency in how ADEs

were defined.

2) Little consistency in how ADEs

were detected. (There are five main

categories of detection techniques:

spontaneous reporting; computerbased screening; case review by a

pharmacist, physician, or nurse;

patient interviewing; medical

records/ICD9 review; and various

miscellaneous techniques. The

studies reviewed by the research

team used one or more techniques

simultaneously for ADE detection.)

3) Little consistency in how the

ADEs were classified and described.

The research team’s goal was to

remedy each confounder in ways

that were explicit, consistent, and

clinically sound. The researchers

adopted the World Health

Organization’s definition of an

ADE and modified it by adding criteria that emphasized clinical significance, as well as by adding

explicit inclusion and exclusion

rules to deal with the dozens of

common variations not easily

accommodated by the standard definition. 

The researchers then put in

place a detection scheme that

stressed the most sensitive ADE

detection techniques described in

the literature, emphasizing clinical

pharmacist case review, patient

interviewing, computer-generated

alerts, and retrospective ICD9 code

review. 

Each suspected ADE was

reviewed by a panel of two physicians, two clinical pharmacists, a

Ph.D.-trained nurse, and a

Masters-level interviewer. This

panel reviewed each component of

the classification form, an eightpage instrument that lists more

than 120 data items (covering

drugs involved, clinical syndrome,

clinical response to the ADE,

causality, severity, preventability,

and error analysis). 

This combination of explicit definition, multiple-detection signals,

and thorough classification and

analysis is unique in the study of

ADEs.

The researchers turned up far

more ADEs than they had expected. They reviewed 939 admissions

(out of 2,036) from Aug. 14, 2000,

through Dec. 31, 2000.

Observation and research study

patients were excluded. Using

their definition of an ADE, which

favors clinically significant events,

the researchers found that:

■ only a small percentage of the

ADEs were mild; 

■ most were moderate (not selflimited and requiring treatment);

and 

■ a significant portion were severe

(required additional hospitalization

or led to a hospitalization or caused

permanent harm or death). 

The researchers found no systematic bias by gender or race.

Complete results will be published

later this year. While it is important to know that ADEs are more

common than expected, the key

outcome of this work lies in its

ability to pinpoint prevention

strategies. Since each adverse

event is thoroughly characterized,

T he key outcome of this

work lies in its ability to

pinpoint prevention 

strategies.

continued on page 7
6

L EGAL PERSPECTIVE

Patient Safety at the VA: Five Lessons in Prevention 

from Tort Claims Experience

By Suzanne C. Will, Regional Counsel, San Francisco

In fiscal 2000, the U.S. government

paid more than $185 million for settlements and judgments to

claimants in medical malpractice

cases, including $68 million paid

out by the VA. In many cases, a

serious or tragic result for a patient

can be traced to a failure to follow

VA’s patient safety rules. A disproportionately large number of these

failures involve nursing homes and

mental health units. 

The Regional Counsel offices

investigate tort claims involving VA

medical facilities throughout the

country. Following are some

observations concerning five common types of safety violations that

we have encountered during the

past five years. The cases cited

here could easily have been prevented; indeed, we think of them as

lessons in prevention. (To protect

the privacy of patients and others,

the facts of the following cases have

been liberally modified and are

based on composites of several

claims that illustrate specific safety

issues.)

#1 Lifting Rules. A local nursing

service lifting policy required at

least two staff members to assist in

lifting, transferring, or turning a

heavy or immobile patient. This

safety rule has a dual purpose: It

prevents the ubiquitous back injury

for staff and ensures that the

patient will not end up on the floor.

People in a hurry tend to forget

these rules, which is what happened with a licensed VA nurse

(LVN) who couldn’t wait until a

second person was able to join him.

The patient had quadriplegia secondary to advanced multiple sclerosis and was considered an immobile

patient. The LVN knew that the

patient was light and thought that

he could easily handle him alone.

He didn’t take into consideration,

however, that the patient’s

advanced disease made his body

stiff and unwieldy. The nurse lost

his grip on the helpless patient,

who fell solidly on his head, resulting in the patient’s death several

days later. Lesson learned: Never

second-guess a patient safety rule.

#2 Spills. The “slip and fall”

case is extremely common in hospitals and underscores the need for

scrupulous maintenance. In one

instance, a patient’s wife came to

visit him, bearing numerous gifts

piled high in her arms. She also

was carrying a large vase of flowers. These objects naturally

obstructed her view of the floor.

To make matters worse, she was

focusing her attention on the room

numbers of the patient rooms. As

a consequence of all these factors,

she slipped on spilled water and

broke her ankle. Lesson learned:

Maintenance and other staff must

be ever-vigilant in keeping floor

surfaces dry, clean, and safe —

particularly on rainy or snowy days

— and entrances, corridors, and

dining areas free of debris, obstructions, and spillages.

#3 Protecting Patients from

Other Patients. In a particularly

alarming case, a combative patient

in a mental health unit became

angry and started choking his vulnerable roommate. Fortunately, a

nurse was walking by and saved

the victim’s life. The attorney

investigating the case was surprised when he found that the

combative patient’s medical record

documented numerous physical

altercations with patients and

other staff in a short time period

prior to the incident. Even worse,

the room that the two patients

shared was in the farthest possible

location from the nurse’s station.

Aside from the medical mismanagement of the combative patient, the

decision to put a defenseless,

incompetent patient together with

a known batterer defied all logic.

Lesson learned: Take affirmative

measures to protect patients and

staff from physically abusive

patients.

#4 & #5 Misplacement of

Restraints and The Unattended

Patient. A combination of safety

failures resulted in a patient’s

death by exsanguination. An ICU

patient had a catheter sutured to

his left femoral vein. The patient

was disoriented, agitated, and

unable to respond to questions.

Because he had attempted to pull

out the catheter, soft wrist

restraints were necessary. When

the ICU nurse on duty applied the

soft wrist restraints, she left too

much slack in the left restraint.

She then positioned the patient on

his left side, and the excess slack

enabled him to pull out the catheter

that had been inserted in his left

groin area. Had he not been able to

reach the catheter, he would not

have been able to remove it. Lesson

learned: Double-check safety

restraints; they are useless if not

applied properly. 

The patient would not have bled

to death, however, if not for a second safety violation. In fact, if the

nurse had not left the patient to go

to the other side of the ICU area,

where she ate an apple and talked

to another nurse for about 30 minutes, the patient might have survived the first mistake. The nurse

also neglected to ask any of the

other nurses on duty to watch her

L esson learned: 

Never second-guess a

patient safety rule. 

continued on page 7
7

patient while she was away. When

she returned, the monitor showed a

flat arterial line tracing. No alarms

had sounded. Later, it was discovered that the EKG lead wires were

defective — yet another contributing cause to the patient’s death.

Lessons learned: Follow a policy of

continuous assessment in an intensive or critical care situation.

Require each nurse to alert another

nurse when he or she is going to be

away from a patient — even if only

for a few minutes — and ensure

that the patient is being attended.

Never rely on mechanical monitors.

Finally, have a solid, well-documented maintenance plan in place

to identify and repair defective

equipment.

Improving compliance with

patient safety rules is essential to

reducing risk of harm to our

patients; it can also save VA millions of dollars in tort claim payments. Working together as

partners, VA managers, clinicians,

and the Regional Counsel offices

can prevent common safety violations. 

In Remembrance of Mark Moskowitz 

Health services researchers across the

United States lost a true mentor and

colleague when Dr. Mark Moskowitz

died on Sept. 1, 2001. It is difficult to

express just how much Dr. Moskowitz

has meant to VA’s HSR&D Program and

staff because he contributed his expertise and consultation on so many levels

for so many years. 

A talented clinician and admired faculty member at Boston University’s

School of Medicine, Dr. Moskowitz was a

trusted advisor and champion of quality

health services research in VA. He was

a member of HSR&D’s Scientific Review

and Evaluation Board for 10 years and

Chair for a number of those years, contributing significantly to quality improvements in the review process

and in health services research proposals. He served on the HSR&D

Subcommittee of the National Research Advisory Council for the

past three years and added his keen perspective to our Quality

Enhancement Research Initiative’s Research and Methodology

Committee since its inception in 1998. 

In 1990, he became one of the original Steering Committee members for HSR&D’s Center for Health Quality, Outcomes, and

Economic Research located in Bedford, Mass. He has since worked

on numerous health services research projects with staff there. 

For the past two years, he also chaired the Steering Committee for

HSR&D’s Center for Chronic Disease Outcomes Research in

Minneapolis, providing exceptional guidance to that Center’s strategic direction. 

Dr. Moskowitz’s commitment to ensuring high-quality health care

and health services research was matched only by his commitment to

interacting in a meaningful way with the people of health care and

health services research and the humor and value he brought to

those interactions. We are deeply grateful for all that he has shared

with us.

HSR&D’s 20th Annual Meeting 

Feb. 13-15, 2002

Celebrating the Past: Shaping the Future is the theme of the next

HSR&D annual meeting, to be held in Washington, D.C., Feb. 13-15,

2002. This event will mark HSR&D’s 20th annual meeting and the

25th anniversary of VA funding for HSR&D. 

To celebrate the occasion, we will feature several special events

and displays recognizing the accomplishments of HSR&D through the

years, as well as many competitively selected workshops, presentations, and posters on current and innovative health services research

in VA. 

For more information about the meeting and registration, visit the

HSR&D web site at http://www.hsrd.research.va.gov .

Will

continued from page 6

Hurdle

continued from page 5

the researchers are already able to

mount specific measures to reduce

the most common ADEs (such as

complications due to opioid analgesics or loop diuretics). 

When the study is complete,

standard regression techniques will

be used to build patient profiles

that indicate high-risk patient categories. Prevention schemes will

then be tailored to improve patient

safety for patients in these categories. Findings to date also suggest a critical need to mount a

correspondingly thorough outpatient

ADE survey, as a surprisingly large

fraction of hospital admissions

were related to outpatient ADEs.
tive risk assessment and analysis, as

well as aggregate-data driven analysis for certain high-frequency

events, such as missing patients,

falls without serious injuries, close

calls associated with medicationrelated events, and suicide

attempts. Our program will continue to leverage the efforts of the RCA

teams over the coming year through

mining of information, analysis of

trends, and sharing of important

evidence-based results. 

We also anticipate increasing our

collaboration with VA researchers

during the next few years. At

NCPS, we are interested in developing solutions and tools that can be

adapted to address local problems

and situations. Some interventions

can be applied to solve broader

problems, and in those cases we

would welcome the opportunity to

work with VA researchers to design

prospective effectiveness studies.

This type of research would help us

identify a best practices base for

common and difficult problems.

8

Martin P. Charns, D.B.A., Editor-in-Chief

Mary Darby, Editor

Geraldine McGlynn, Co-editor

ADVISORY COMMITTEE

John G. Demakis, M.D., Director, VA HSR&D

Rodney A. Hayward, M.D., VA HSR&D

Center of Excellence, Ann Arbor

David H. Law, M.D., VA Medical Center, 

Bay Pines, FL

Shirley Meehan, M.B.A., Ph.D., VA HSR&D

Alan S. Perry, M.H.A., FACHE, VA Medical

Center, Fresno, CA

Robert M. Roswell, M.D., VA Network #8,

Bay Pines, FL

Hanna B. Rubins, M.D., M.P.H., VA HSR&D

Center of Excellence, Minneapolis

FORUM is a publication of the VA Office of Research &

Development, Health Services Research & Development

Service, Management Decision and Research Center, in

conjunction with the Academy for Health Services Research

and Health Policy.

F O R U M

Effective quality indicators must

either directly measure or be clearly linked to definable processes of

care. Only through this linkage

can providers figure out how to fix

problems. Likewise, these quality

indicators and processes must be

clearly linked to outcomes that are

important, through experimental

evidence in the literature or a large

body of observational studies. Both

ends of the bridge are important.

Although the current trend to use

process measures as indicators

appears to obviate the need to conduct validation studies such as this

one, the number of process measures with clear evidence of a link

to outcomes of care is limited.

Many intermediate outcomes —

such as level of glycemic control,

blood pressure measurement, lipid

levels, and so forth — continue to

be popular indicators. In that light,

the cautions supplied by this study

take on added importance for the

development and use of future such

indicators. 

Hofer

continued from page 4

Invited Commentary

continued from page 2

(1)Hofer TP, Bernstein SJ, Demonner

S, Hayward RA. Validating Quality

Indicators for Hospital Care. Jt Comm

J Qual Improv. 1997; 23(9):455.

(2)Hofer TP, Bernstein SJ, Demonner

S, Hayward RA. Developing new quality indicators: A case study of electrolyte

disorders and drug toxicity acquired in

the hospital. (manuscript in preparation)