United States Department of Veterans Affairs
VA Sunshine Healthcare Network


VISN 8 Patient Safety Center of Inquiry, Tampa



The mission of our center is to support clinicians in providing safe patient care by designing and testing safety defenses related to the patient, provider, technology, and organization. Specifically, our PSCI goals are to:

  1. prevent injurious falls (specifically focusing on the most serious injuries: hip fractures and intracranial hemorrhages) and minimize adverse events associated with hazardous wandering;
  2. promote the safe use of technology associated with injurious falls and hazardous wandering; and
  3. promote a culture of safety to support clinicians in providing safe patient mobility.

The VISN 8 Patient Safety Center of Inquiry (PSCI) is part of the James A. Haley Veterans' Hospital in Tampa, Florida. Our PSCI has a track record of evaluating and translating patient safety research findings into standard practices that are disseminated and implemented to improve patient safety across the entire VHA system. We evaluate the science and determine when research is ready to be "translated." Translation involves designing and testing clinical tools (e.g. algorithms, protocols, policy templates, resource guides, patient and staff education materials) to facilitate patient safety and reduce adverse events. We pilot test these tools at the Tampa VA, and then in VISN 8. Successful program elements are then exported to the NCPS (National Center for Patient Safety) for national implementation. The following PSCI objectives were identified:

  1. Evaluate the strength of the evidence to identify knowledge gaps to target for future inquiry and findings ready for translation to practice;
  2. Define existing practice patterns and outcomes across the VA and determine current variation from established best practices;
  3. Identify and implement interventions to change practices to strengthen patient, provider, and systems level safety defenses, through the design of tools and products specifically designed to promote patient safety, such as clinical tools; cognitive aids; educational materials; policy reports, VHA information letters, handouts, and/or directives; and others;
  4. Improve technology safety defenses through biomechanics, human factors engineering, and other principles of design;
  5. Evaluate and document the process and outcomes of best practices at the patient, facility, VISN, and VHA level; and
  6. Collaborate with NCPS to develop a VHA business case and implementation plan to export evidence into practice.

Items of Interest