Health care exists in an evolving political

landscape. Currently, the new presidential

administration is driving demand for accountability. This accountability often takes

the form of demands by legislators and

third party payers for assurances of patient

safety and positive outcomes.

Patient safety is a complex phenomenon encompassing myriad factors and disciplines.

Standards of practice must evolve in a manner that keeps pace with reality. Health care

leaders must be willing to challenge the conventional wisdom that created sacred cows

and to move toward evidence-based practice. Systems must encourage safety in

patient care and eliminate opportunities

for error. An interdisciplinary approach can

refocus organizational goals so that quality

and safety drive clinical initiatives. VHA is

well positioned to create environments

of safety because of such gold standard

approaches as the Computerized Patient

Record System (CPRS) and Bar Code Medication Administration (BCMA).

Organizational Culture:

A Powerful Tool

Organizational culture is a powerful tool

that leaders use to create change and to

drive operational initiatives. A nexus of

safety, medication management, and informatics can set the stage for systems redesign, and creates an organizational culture

that is centered on patient safety. With respect to patient safety, the concept of “just

culture” has become important. As contrasted with the notion of a “no blame” culture, “just culture” seeks to promote learning through analysis of errors and near

misses, as opposed to simply resorting to a

disciplinary process.

1

Rethinking conventional wisdom provides a

basis for creating opportunities for safety.

For instance, several generations of nurses

have been taught that maintaining four side

rails in the upright position provides safety

for the patient. Evidence has demonstrated

that four side rails can be detrimental to

safety and should be avoided in favor of

low beds, more frequent comfort rounds to

eliminate the most frequent cause of falls,

and reducing the incidence of polypharmacy.

Falls incidence is one of the nurse-sensitive

measures closely tied to the issue of patient

safety. Other measures include pressure

F

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for Veterans

Commentary

Opportunities for Ensuring a Safe Environment

Cynthia Caroselli, R.N., Ph.D., VA New York Harbor Health Care System, New York,

New York

December 2009

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlights

• Prescription Drug Facts Box 4

• Suicide Prevention 6

Organizational Profile

• Tampa Center of Excellence 7

A publication of the VA Office of Research & Development,

Health Services Research & Development Service, Center

for Information Dissemination and Education Resources, in

conjunction with AcademyHealth.

“Systems must encourage safety in

patient care and eliminate opportunities for error. An interdisciplinary

approach can refocus organizational

goals so that quality and safety drive

clinical initiatives. VHA is well

positioned to create environments

of safety because of such gold

standard approaches as the Computerized Patient Record System

(CPRS) and Bar Code Medication

Administration (BCMA).”
ulcer incidence, central line infection rates,

ventilator associated pneumonia, and failure

to rescue. These phenomena offer opportunities to redesign practice based on evidence. While historically health care has

been insular in its approach to performance

improvement, contemporary practice is enriched by benchmarking from sources external to health care such as the aerospace

industry for accident prevention and the

hospitality industry for patient satisfaction

programs. Such endeavors provide direction

for creatively improving practice.

Errors Provide Opportunity for

Learning

Realistically, although clinicians and administrators strive to achieve a zero defects outcome, it has to be assumed that errors will

occur. Such situations must provide opportunities for learning. Root cause analysis

(RCA) provides a venue to learn from clinical errors by dissecting the routes by which

the error occurred, analyzing the consequences, and creating hard fixes to prevent

future errors. While conventional wisdom

would advocate keeping errors confidential,

involving front line staff and publishing an

abbreviated report of the RCA allows for

learning to occur on a wider scale. Thus,

evidence-based knowledge is made available

to those most intimately involved in errorprone circumstances.

Medication management represents an area

of risk for many health care providers, especially nurses, that can provide opportunities

for learning. Individual patient risk increases

with polypharmacy and the use of high-risk

medications. VHA has long been a leader in

medication safety with the introduction of

CPRS and BCMA. Both of these products

are far more than data depositories. Inherent in their creation was the design of safety

devices and prevention strategies. Coupled

with the performance measure and external

peer review programs, it is possible to monitor practice patterns and organizational

achievement of targets to determine improvement foci.

Role of Clinical Informatics

Clinical informatics is the vehicle by which

safety measures are enhanced and standards

of care are refined. Rather than leaving this

important endeavor to a centralized “IT”

department, clinician-informaticists create

systems that reflect the realities of experience at the point of care and address the

needs of front line staff. Systems should accomplish much more than record keeping:

they must scan for iatrogenic effects of care

delivery that are likely results of the increasing complexity of health care. Involving the

end user in system redesign can do much to

obviate the need for workarounds, which

often result from system failures that did

not anticipate the demands of clinical reality.

In short, the complexity of contemporary

health care is fraught with opportunities for

error. This environment demands an interdisciplinary approach that questions conventional wisdom and does not subscribe to

the notion that accidents are largely unpreventable. New approaches refine systems of

care delivery that build in safety from their

inception yet acknowledge that errors provide learning opportunities. Successes and

failures are shared with all care providers so

that a culture of safety is created. While

these efforts require a commitment of energy and resources, the stakes are far too

high to gamble with the lives of our patients. Based upon its advantages in systems

design and performance improvement,

VHA can be a leader in reforming health

care for the nation and the world.

Reference

1. Sorra JS & Nieva VF (2004). Hospital Survey on

Patient Safety Culture. AHRQ Pub. No. 04-0041.

Director’s Letter

Last January, HSR&D launched its pilot study research initiative. Pilot study submissions are a maximum of 10 pages, one

year duration, and $100,000. The goals of the pilot study

program are to encourage the collection of data to improve the

quality of subsequent Investigator Initiated Research (IIR) proposals, provide a simplified mechanism for investigators early

in their careers to obtain funding, and provide initial support

for innovative research that might be considered too risky for the IIR mechanism.

Pilot projects will allow investigators to refine research objectives, designs, and

methods to better address HSR&D priority areas. For example, pilot projects

might be “mini-versions” of a potential multi-center randomized trial, or might

focus on refining surveys or questionnaires to strengthen a larger project. Moreover, pilot projects provide opportunities for investigators to explore novel

research issues through small-scale initiatives. Areas of HSR&D priority interest

include but are not limited to: post-deployment health, traumatic brain injury,

mental health, rural health, health services genomics, and the care of complex

chronic conditions. For more information about the HSR&D Pilot Project program, visit www.hsrd.research.va.gov/funding/solicitations.cfm.

Over 40 percent of 82 pilot project proposals reviewed at the August Scientific

Merit Review Board (SMRB) will be funded. HSR&D looks forward to dynamic research projects from our talented investigators, who strive to improve the quality

of health and health care for our nation’s Veterans.

Seth A. Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service December 2009
VA Office of Research & Development, Health Services Research & Development Service December 2009

As reported by the Institute of Medicine,

medical errors are the fifth leading cause of

death in the United States and cost a staggering $29 billion annually. Patient safety

has become a major concern in the U.S.

health care system and the VHA as well.

Cynthia Caroselli describes the complexities

in the health care arena that affect patient

safety, including issues at the point of care

delivery as well as political influences that

shape the culture of the VHA. She argues

that the VHA is well positioned to be a

leader in patient safety, and analyzes two

critical considerations about patient safety in

the VHA to which I would like to respond.

Interdisciplinary Approach 

The first consideration is that an interdisciplinary approach is needed to create a culture of patient safety. She provides several

examples of contributions from nurses to

monitor and improve patient safety and

states that patient safety in the VHA can be

enhanced by systems such as the CPRS and

BCMA. This is all true and the VHA has

made some significant contributions to patient safety. However, more information

about interdisciplinary collaboration to improve patient safety is needed. More research and program evaluation is needed to

evaluate the outcomes of interdisciplinary

approaches to patient safety. Patient safety is

not discipline-specific and yet, much of the

responsibility rests with nurses. Some interdisciplinary strategies have been proposed,

however, including the importance of communication. 

One example of an interdisciplinary approach that could improve patient safety is

developing interdisciplinary patient care

standards and evidence-based practices.1

Other examples include interdisciplinary 

approaches to teamwork, shared governance, and patient rounds—all of which

have been found to improve patient safety.2

We also need to develop an effective 

infrastructure to support interdisciplinary

monitoring to reinforce that patient safety 

is a shared responsibility. These interdisciplinary approaches may help health care 

organizations create a culture of patient

safety, reduce costs, and save lives.

Caroselli’s second point is that not all errors

are preventable and that when they do

occur, organizations should use these events

as learning opportunities. This point is an

important one. The challenge for the VHA

is to use system re-design methods to 

convert health care organizations into 

learning organizations. Organizations that

develop into learning organizations have 

the ability to identify knowledge gaps, trust

opposing views, reflect on experiences, and

tolerate errors. Bureaucracy and political 

environment influence the culture of the

VHA, which may discourage reporting 

of errors and unintentionally impose 

penalties for errors. These influences may

decrease the likelihood that errors will 

be acknowledged. 

Learning Organization Tenets 

These processes may preclude a culture of

patient safety that is based on the tenets of

a learning organization. The political environment often creates a protective response

from leaders that may shape the organization toward a restrictive system that is hesitant to openly acknowledge and deal with

errors. The three building blocks for learning organizations to develop are: 1) a supportive learning environment; 2) concrete

learning processes; and 3) leadership that 

reinforces learning.3 These building blocks

provide a structure for assessing performance and identifying areas for improvement

to promote a learning organization. 

Integrating three powerful processes—developing interdisciplinary approaches to 

patient safety, creating learning organizations

that support a culture of safety, and the 

research expertise in the VHA—will increase

performance and reliability of services in

health care. Innovations being developed in

patient safety centers of excellence provide

a unique opportunity to evaluate structure,

process, and patient safety outcomes using

research methods. As the VHA continues

its strong commitment to system re-design

processes, it is more likely to become a true

learning organization. However, leaders will

have to embrace leadership styles that promote trust and that view errors as learning

opportunities. Nursing leadership teams can

define strategies for developing interdisciplinary teams to monitor and promote patient

safety. The VHA is committed to building a

culture of safety across the continuum of

care, including home care—an often overlooked area for promoting safe environments for Veterans. The VHA is well

positioned to build research programs to

test organizational strategies for each of 

the building blocks of learning organizations and to disseminate research-based 

information to help leadership teams use

these strategies to build a stronger culture

of safety in their facilities. Linking the VHA

research expertise with evaluation of 

innovative strategies will make a significant

contribution to promoting safe care 

for Veterans.

References

1. Hougaard J, Developing Evidence-Based Interdisciplinary Care Standards and Implications for Improving 

Patient Safety. International Journal of Medical Informatics 

2004, 73(7), 615-24.

2. Sherwood G, et al. A Teamwork Model to Promote 

Patient Safety in Critical Care, Critical Care Nursing 

Clinics of North America 2002, 14(4), 333-40.

3. Garvin DA, Edmondson AC, and Gino F. Is Yours 

a Learning Organization? Harvard Business Review 2008,

86(3), 109-116, 134.

Response to Commentary

Building a Culture of Patient Safety 

Maude Rittman, Ph.D., R.N., North Florida/South Georgia Veterans Healthcare

System, Gainesville, Florida
The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

People need accurate, understandable information to make wise decisions about medical care. Yet much of what they receive is

marketing designed to generate enthusiasm

for new products by highlighting benefit

and minimizing harm. Balanced data promoting informed decision making about

medical interventions—including the decision to forgo them—is far less common.

Problems with Drug Information

Direct-to-consumer (DTC) advertising for

prescription drugs is the most prominent

example of how medical interventions are

marketed to the public. Industry spent more

than $5 billion on these ads in 2007—more

than twice the total U.S. Food and Drug

Administration (FDA) budget. Although

proponents claim they serve an educational

purpose, the ads generally fail to relate the

most fundamental information consumers

need: how well the drug works. Not surprisingly, consumers tend to overestimate treatment efficacy.

DTC advertisements are only one way that

patients learn about medications. Theoretically, prescribing physicians summarize drug

benefits and harms, although this probably

does not occur often in practice. When they

fill their prescriptions, patients may receive a

variety of information sheets, patient package

inserts, or medication guides. A recent FDA

survey found, unfortunately, that these information sheets (which provide instructions

about use, but rarely if ever quantify benefit

and harm) are often illegible and hard to

understand. Even the most complete prescribing information—the prescription drug

label—written by industry and approved by

the FDA—can be incomplete and biased.

1

A Practical Idea: The Drug

Facts Box

To clearly communicate prescription drug

benefits and harms, we developed a single

page, standardized format called the “prescription drug facts” box (see example). The

box is modeled on FDA’s nutrition facts box,

a format already familiar to consumers. Data

for drug boxes would come from the studies

used in FDA’s drug approval process. Ideally,

boxes would be written by FDA’s reviewers

during the drug approval process. The reviewers, independent experts with complete

access to the relevant published and unpublished data, could ensure that everyone knows

what FDA knew at the time of approval.

VA Office of Research & Development, Health Services Research & Development Service December 2009

Research Highlight

The Prescription Drug Facts Box:

Helping Doctors and Patients Make

Wise Choices

Lisa M. Schwartz, M.D., M.S., and Steven Woloshin, M.D., M.S.,

VA Outcomes Group, Department of Veterans Affairs Medical Center,

White River Junction, Vermont
VA Office of Research & Development, Health Services Research & Development Service December 2009

e

HSR&D Research Featured in Journal Supplements and

Special Issue

VA HSR&D research is featured in two special journal supplements—Journal of

Rehabilitation Research & Development (JRRD) and the Journal of General

Internal Medicine (JGIM), and in one special issue of Pain Medicine.

As a follow-up to a Pain Research Summit held by VA’s Rehabilitation R&D Service

and VA/HSR&D’s Polytrauma and Blast-Related Injury Quality Enhancement

Research Initiative (PT/BRI-QUERI), a series of papers was published in a special

issue of Pain Medicine [October 6, 2009;10(7)]. Among Veterans receiving primary

care in VA health care facilities, as many as 50 percent of men and 75 percent of

women report the presence of pain. Similarly high rates of pain are documented

among Veterans returning from deployment in Iraq and Afghanistan. This special

issue of Pain Medicine considers the evidence for the assessment and management of pain in this population, and focuses on the most prevalent and challenging of pain conditions observed among newly returning Veterans. In

addition, HSR&D is planning a series of cyber seminars featuring authors from

the Pain Medicine special issue. The cyber seminar schedule is available at:

www.hsrd.research.va.gov/for_researchers/cyber_seminars/catalog.cfm.

The November 2009 issue of JRRD includes papers commissioned for the 2008

VA Office of Research and Development State-of-the-Art (SOTA) Conference:

“Research to Improve the Lives of Veterans: Approaches to Traumatic Brain Injury Screening, Treatment, Management, and Rehabilitation.” The SOTA focused on traumatic brain injury (TBI)—sometimes referred to as the ‘signature

injury’ of the conflicts in Iraq and Afghanistan. Articles address topics ranging

from care coordination with the DoD to the pathology of blast-related brain injury to community integration for Veterans with TBI.

In January 2010, a Special JGIM Supplement will feature 10 articles written by

QUERI investigators. The theme of the Supplement is ‘Connecting Research

and Patient Care,’ and it will focus on lessons learned about implementing evidence-based interventions into clinical practice through the QUERI program.

These lessons are particularly important given national health care reform efforts and the need to speed up and sustain improvements in our health care

system. Specific topics addressed in the Supplement include: organizational

readiness in specialty mental health care, connecting research and patient care,

and the use of electronic clinical reminders for brief alcohol counseling.

Drug facts boxes could serve a variety of

purposes including: an executive summary

of the FDA review documents, a replacement for the current “brief summary” (the

FDA required, small print 2nd page) on

direct-to-consumer drug ads, and as standalone information sheets for doctors and

patients. The approach could easily be used

for devices and surgical procedures as well.

Does the Drug Box Help?

We have published a number of studies,

including two national randomized trials,

showing that consumers want the information

in the drug box, understand it, and can use

it.

2,3 Most importantly, the box helps consumers

make better decisions about prescription

drugs. For example, we randomized 231

consumers to see either standard drug advertisements or ads with drug facts boxes

for two medications used to treat heartburn.

The drugs were selected so that they had

similar side effect profiles, but one clearly

outperformed the other. We found that the

drug box group was more than twice as likely

as the standard ad group to choose the better drug: 68 percent vs. 31 percent, p<0.001.

The Drug Box and FDA Policy

In a pilot project, we have shown that FDA

reviewers can create drug boxes. We worked

with 10 FDA medical reviewers who iteratively

drafted, critiqued, and revised boxes for a

variety of drugs. To develop a transparent,

replicable process for creating drug facts

boxes, we also developed a handbook to

guide subsequent production of drug boxes.

Earlier this year, the FDA’s Risk Communication Advisory Committee voted unanimously

in a non-binding recommendation that FDA

“should adopt the Drug Facts Box format

as its standard for communicating essential

information about pharmaceuticals” in the

drug label, advertisements, and other consumer materials. Most recently, Senators

Reed (RI) and Mikulski (MD) introduced

legislation (S. 1142, the Informed Health

Care Decision Making Act, May 21, 2009)

calling on the Secretary of the Department

of Health and Human Services to review

the evidence supporting the drug facts box,

and if satisfied that the box would improve

health care decision making by clinicians

and patients and consumers, to “promulgate

regulations as necessary to implement such

format.” The legislation has been incorporated into the Senate’s health care reform

bill, the “Patient Protection and Affordable

Care Act” now under consideration.

Helping patients make informed decisions is

fundamental to good medical practice and

has long been a VA priority. Drug facts boxes—

ideally produced by the FDA—would help

inform decisions about prescription drugs

by providing doctors and patients with access to key information about drug benefits

and harms in an understandable format.

References

1. Schwartz LM, Woloshin S. Lost in Transmission--

FDA Drug Information that Never Reaches Clinicians.

New England Journal of Medicine 2009; 361: 1717-20.

2. Schwartz L, Woloshin S, Welch HG. Using a Drug Facts

Box to Communicate Drug Benefits and Harms: Two

Randomized Trials. Annals of Internal Medicine

2009;150:516-27.

3. SchwartzLM,Woloshin S,WelchHG.TheDrugFactsBox:

Providing Consumers with Simple Tabular Data on Drug

Benefit and Harm. Medical Decision Making 2007; 27(5):655.
Recent reports indicate that suicide rates are

higher among U.S. Veterans when compared

with non-Veterans. Veterans who completed

the U.S. National Health Interview Survey

(NHIS) between 1985 and 1996 had higher

suicide rates than non-Veterans. Data from

the National Violent Death Reporting System in 16 states also indicate higher than expected rates of suicide among Veterans

living in the community.

1 Suicide rates have

been increasing among active duty Army

soldiers and now surpass age and gender-adjusted suicide rates in the general population.

Of direct interest to VHA investigators focused on health system safety, the VHA has

assessed suicide mortality among its entire

patient population—the only large health

care organization to do so. In 2001, suicide

rates among VHA health care users were 66

percent higher than the age and gender adjusted general U.S. population. The crude

suicide rate among male and female VHA

users was 43.1/100,000 and 10.4/100,000

person-years, respectively; whereas, the crude

suicide rate among males and females in the

general population was 23.2/100,000 and

5.2/100,000 person-years, respectively.

2 The

capability of determining and following suicide rates in its patient population gives the

VHA unparalleled opportunities for assessing

the efficacy of suicide prevention programs.

Suicide Prevention Activities

in VA

Because of its high-risk population and the

priority placed on suicide prevention, the

VHA has worked to improve access to evidence-based mental health services, and to

develop and implement comprehensive suicide prevention programs. A Veteran-specific telephone hotline option has been

implemented in cooperation with the National Suicide Prevention Lifeline. Veterans

who call the Lifeline number can press “1”

to be routed to trained VHA mental health

employees who have access to patients’

medical records and who work with VHA

suicide prevention coordinators to ensure

systematic follow-up of Veteran callers.

VHA has placed suicide prevention coordinators at all VHA facilities to provide ongoing suicide training for staff; identify, track,

and monitor high-risk patients; coordinate

suicide prevention activities with community agencies; develop local prevention

strategies; and participate in patient safety

and environmental analysis (e.g., assess the

safety of inpatient units). VHA will soon

initiate additional initiatives to reduce suicide.

VA Office of Research & Development, Health Services Research & Development Service December 2009

Research Highlight

Suicide Prevention

Marcia Valenstein, M.D., M.S., Research Scientist, Department of Veterans

Affairs Center for Clinical Management Research, and the Serious Mental

Illness Treatment Research and Evaluation Center, Ann Arbor, Michigan

Reducing Suicides in Veterans

by Steven Bagley, M.D., M.S., VA Greater Los Angeles Health Care System

Suicide prediction and reduction are pressing issues for VA. Many Veterans have

significant risk factors, such as mood disorders, substance use disorders, pain,

disabling chronic medical illness, traumatic brain injury, posttraumatic stress

disorder (PTSD), and skill in using firearms. Clinical prediction is a challenge

because it requires forecasting a single infrequent act of behavior. The low

base rate of suicide in the population means that widespread use of screening

tests generates many false positives. Therefore, most clinical attention has

been devoted to organizing the interventions by risk strata, typically by providing

low-intensity interventions, such as suicide awareness programs, to populations,

and higher-intensity interventions, such as case management or post-discharge

tracking, to those in high-risk groups or with known risk factors such as prior

suicide attempts.

VA has already implemented several suicide reduction programs, and much of

this has been coordinated through the Center of Excellence in Canandaigua,

New York, and the Mental Illness Research, Education, and Clinical Center in

Denver, Colorado. As Valenstein mentions in her research highlight, Suicide

Prevention Coordinators (SPCs) are now located at each VA facility. Computerized clinical reminders screen patients for depression, PTSD, and alcohol

abuse. A suicide risk “flag” aims to close gaps in treatment, expedite access

and follow up, and alert non-medical health providers to keep an eye open for

signs of depression or decompensation.

Risk stratification requires knowing details about prior attempts. Policy planning

and program evaluation requires accurate aggregate statistics on attempts

and completions. It is well recognized that ambiguity exists in the informal

vocabulary used (such as “ideation” and “attempt”), and considerable work

remains to be done to define terms that can be easily used across different

disciplines with accuracy and ease. Further work will also be needed to ensure

that comprehensive surveillance of suicide attempts and completions in

Veterans is routinely conducted and reported. There are numerous research

questions about multifaceted suicide reduction programs—even if they are

robustly successful, the question remains as to which facets are causally

related to reductions in suicides, and whether there are facilitative or synergistic

effects among the program components.

continued on page 8
VA Office of Research & Development, Health Services Research & Development Service December 2009

Under the leadership of Dr. Audrey Nelson,

investigators at the HSR&D/RR&D Center

of Excellence (COE) in Tampa, Florida

have made significant contributions to both

staff and patient safety in VA and in health

care across the country.

Over the past 30 years, efforts to reduce

work-related musculoskeletal injuries in health

care relied on body mechanics classes or

training in lifting techniques, both of which

have been unsuccessful. At the COE, Dr.

Audrey Nelson leads a program of research

and research translation in safe patient handling that is now culminating in a $200 million VA-wide implementation program. This

program is designed to radically change the

way nurses and other direct health care

providers move and transfer dependent patients, from manually lifting and pulling to

an ergonomics-based program featuring

technologies to mechanically move them.

Through studies funded by VA and others,

researchers documented that an ergonomicsbased program will decrease the number

and severity of patient handling injuries, decrease the cost of health care by decreasing

workers’ compensation costs, and result in

increased comfort and dignity for patients.1

Dr. Nelson works with schools of nursing

across the country to implement a curriculum for colleges of nursing co-developed

with the National Institute for Occupational

Health and Safety.2

Researchers at the COE in Tampa have also

made strides in the areas of falls prevention

and fall-injury prevention. Patient falls are

the most frequent adverse event with injury

within the VHA and are the leading cause

of injury-related deaths among people age

65 and older. Researchers at the COE are

addressing gaps in the literature such as the

lack of research on falls among patients

who use wheelchairs for mobility, fall prevention in impairment-specific populations,

and prevention of fall-related injuries. Key

research findings in these areas from recently funded studies include the following:

■ People with spinal cord injuries who use

wheelchairs have a different fall risk profile

compared to other populations. In a

prospective epidemiological study, investigators identified six predictors of wheelchair

falls: pain in previous two months, alcohol

abuse, greater motor function, previous fall,

fewer spinal cord injury years, and shorter

length of wheelchair. Predictors of injurious falls were: pain in previous two months,

greater motor function, previous fall, and

inaccessible home entrance. Results are

being used to develop a reliable and valid

screening instrument, and in the testing of a

wheelchair skills training program.

■ Using an innovative probabilistic risk

modeling method, researchers identified key

high-risk behaviors in VA community living

centers that contribute to fall injury risk.

These behaviors included staff failure to respond to fall alarms in a timely manner, residents’ use of unsafe transfer techniques,

and residents’ use of wheelchairs that are

not properly maintained. Results are being

used to develop a staff training program

that targets these three at-risk behaviors.

References

1. Nelson A, et al. Development and Evaluation of a

Multifaceted Ergonomics Program to Prevent Injuries

Associated with Patient Handling Tasks. International

Journal of Nursing Studies 2006, 43(6), 717–33.

2. Nelson A, et al. Effectiveness of an Evidence-Based

Curriculum Module in Nursing Schools Targeting Safe

Patient Handling and Movement. International

Journal of Nursing Education Scholarship 2007, 4(1).

Organizational Profile

New Center of Excellence in Tampa,

Florida

Gail Powell-Cope, Ph.D., ARNP, FAAN, HSR&D/RR&D Center of Excellence,

Tampa, Florida

HSR&D Deputy Director Named

Effective August 2009, VA’s Health Services Research

and Development Service (HSR&D) welcomed Andrew

Guccione PT, PhD, DPT, FAPTA, as its Deputy Director.

In his role as Deputy Director, Dr. Guccione will direct

his efforts to ensuring the integrity of the scientific

merit review process; developing partnerships to advance HSR&D’s strategic plan; and fostering collaborations across health services, clinical science, and rehabilitation research to

enhance the quality of health care for Veterans. Dr. Guccione is no stranger to

HSR&D, having served for a year and a half as the Scientific Program Manager

for HSR&D’s Mobility, Activity, and Function and Quality Measurement Development portfolios before accepting the Deputy Director appointment.

Prior to joining HSR&D, Dr. Guccione served for ten years as Senior Vice President for the Division of Practice and Research at the American Physical Therapy Association. He also spent six years at Massachusetts General Hospital,

where he was Director of Physical Therapy Services for three years, and Director

of Quality Assurance, Research, and Education for three years. “I look forward

to assisting VA HSR&D investigators in the field through streamlined processes

and enhanced communications so we can more efficiently review and fund

health services research to improve the quality and cost of health care for

Veterans,” Dr. Guccione told FORUM.
David Atkins, M.D., M.P.H.,

QUERI Director,

VA Central Office,

Washington DC

Peter L. Almenoff, M.D.,

FCCP, Assistant Deputy

Under Secretary for Health

for Quality and Safety, VA

Central Office, Washington

DC

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient

Services & Chief Nurse

Executive, VA New York

Harbor Health Care System,

New York, NY

Martin P. Charns, D.B.A.,

Director, VA HSR&D Center

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc

Director, HSR&D

VA Central Office,

Washington DC

Joseph Francis, M.D., M.P.H

Acting Chief Quality and

Performance Officer, VA Cen

tral Office, Washington DC

Rodney A. Hayward, M.D.,

Co-Director, VA HSR&D

Center of Excellence,

Ann Arbor, MI

Alan S. Perry, M.H.A.,

FACHE, Director, VA

Central California Health

Care System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Center of Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

Evidence for Suicide Prevention

Effectiveness

A literature synthesis on suicide prevention

was commissioned from the HSR&D

Evidence-based Synthesis Program (ESP).

3

This synthesis updated the Mann, et al. review

of articles published between 1966 through

June 2005 to May 2008 and focused on Veteran and military relevant articles. The synthesis identified seven multifaceted studies

of military personnel and three studies of U.S.

Veterans. The review also identified twenty

controlled trials of interventions for individuals

who were post-suicide attempt and a large

number of observational studies of restricting access to lethal means. The synthesis determined that the quality of the evidence

supporting most suicide prevention strategies

is low (i.e., further research likely to have an

impact on the estimate of effect) or very

low (i.e., any estimate of effect is uncertain).

The review concluded that multi-component interventions in military personnel

probably reduce suicide risks, although

questions remain regarding the relative importance of different components and the

impact of these interventions in non-military populations. The synthesis also determined that there are insufficient studies of

suicide prevention programs in Veterans to

draw conclusions. Research on psychosocial

interventions following a suicide attempt

had produced a moderate level of evidence

that indicated that these interventions were

only minimally effective. The synthesis

found insufficient data to reach any conclusions about the effectiveness of Community-based Suicide Prevention Centers and

determined that there are no studies that assessed the specific effectiveness of hotlines,

new outreach, counseling, or treatment coordination programs. Restriction of access

to lethal means was thought to have an effect on cause-specific suicides although the

quality of evidence was low.

Opportunities for VA Research

Given the limited evidence for the effectiveness of most suicide prevention efforts, further research in this area is imperative. The

VHA has large patient numbers, a strong

mandate to reduce suicide rates among its

patients, and coordinated roll outs of suicide prevention programs—making it one

of the few health systems in which rigorous

research on suicide prevention is possible.

VHA researchers are thus poised to lead the

way in the area of suicide prevention—to

the benefit of both Veterans and the general population.

References

1. Testimony by The Honorable James B. Peake M.D.

House Committee on Veterans’ Affairs. May 6, 2008.

2. McCarthy JF, Valenstein M, et al. Suicide Mortality

Among Patients Receiving Care in the VHA Health

System. American Journal of Epidemiology. 2009; 169:

1033-8.

3. Greater Los Angeles Veterans Affairs Healthcare

System and Southern California/RAND Evidencebased Practice Center (2009). “Strategies for Suicide

Prevention in Veterans.”

Suicide Prevention

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