Analysis and Mitigation of Reported Informatics Patient Safety Adverse Events at the Veterans Health Administration

Collecting reports of adverse events is a critical part of a comprehensive patient safety program. However, there is no standard practice for translating such reports into design changes. This paper describes the process used by the Department of Veterans Affairs (VA) Informatics Patient Safety (IPS) Office, within the Office of Informatics and Analytics, for analyzing informatics-based adverse events that pose a risk to patient safety. Development of effective design interventions comes from a consistent, systematic process including use of multi-disciplinary analysis teams, standardized tools, and human factors principles. This paper describes the IPS process, presents design-intervention examples, and discusses lessons learned. While challenges remain, the IPS process represents an effective, human-centric process that contributes to a positive culture of safety in VA.