VA selects 10 Patient Safety Centers of Inquiry for special funding

U.S. Department of Veterans Affairs

WASHINGTON — The U.S. Department of Veterans Affairs (VA) is funding 10 VA Patient Safety Centers of Inquiry (PSCI) over the next three years (2019-2021) to develop innovations to improve patient safety throughout VA.

“The PSCI program is the pre-eminent patient safety innovation network in the Veterans Health Administration (VHA),” said VA Secretary Robert Wilkie. “Since 1999, the interventions implemented through the PSCI program have significantly contributed to our Veterans receiving the safest care anywhere.”

PSCI initiatives that have led to key improvements in patient safety include the creation of toolkits for the prevention of patient falls, moderate sedation techniques for use by non-anesthesiologists, protocols for reducing hospital-acquired infections, suicide prevention strategies and a cancer care tracking system.

The 10 centers were selected by an interdisciplinary review committee from the VA National Center for Patient Safetythat consists of patient safety experts, including physicians, nurses, psychologists and pharmacists. There were 36 applicants. The 10 centers selected, including a description of their PSCI initiatives, are listed below:

1. The VA Ann Arbor, Michigan, PSCI will focus on appropriate use of catheters and Peripherally Inserted Central Catheter lines.

2. The Center for Medication Safety in Aging located at the James J. Peters VA Medical Center will serve as a communications hub for efforts to reduce adverse medication effects in older adults and those with dementia.

3. The Ralph H. Johnson VA Medical Center’s PSCI in Charleston, South Carolina, works to improve outcomes for Veterans moving back and forth from VA and non-VA care, specifically focusing on medication safety.

4. The Michael E. DeBakey Houston VA’s Diagnosis Improvement Safety Center (DISCovery) works to prevent diagnostic errors by improving timely follow-up of abnormal test results.

5. The goal of the Iowa City VA’s Center for Antimicrobial Stewardship and Prevention of Antimicrobial Resistance program is to create automated risk-adjusted metrics that are adaptable to the diverse care settings across VA’s health system.

6. The VA Greater Los Angeles Healthcare System’s PSCI will focus on transitions for elderly Veterans and those with complex conditions. They will test the impact of these transitions on 30-day readmissions and patient satisfaction.

7. The VA Puget Sound Health Care System’s Supporting Primary Care Providers in Opioid Risk Reduction and Treatment program identifies patients at high risk for adverse opioid events and monitors their opioid use. It provides guidance on tapering opioid prescriptions and provides supportive connections among patients with opioid use disorders.

8. The PSCI at the James A. Haley Veterans’ Hospital in Tampa, Florida, works to prevent adverse events related to mobility/immobility focusing on prevention of injurious falls, safe patient handling/mobility and pressure ulcer prevention.

9. The Doris Miller VA Medical Center PSCI in Waco, Texas, is developing practical solutions to reduce suicide among Veterans not receiving VA care.

10. The White River Junction, Vermont VA PSCI’s goal is to test evidence-based programs to decrease suicide risk following psychiatric discharges of Veterans.

VA’s National Center for Patient Safety — headquartered in Ann Arbor, Michigan — was established in 1999 to develop and nurture a culture of safety throughout VHA. The primary goal of NCPS is the nationwide reduction and prevention of inadvertent harm to patients. For more information, visit

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