As part of the AHA's continuing efforts to improve patient safety, we've teamed up with the Department of Veterans Affairs National Center for Patient Safety (VA NCPS) to offer hospitals the Strategies for Leadership A Toolkit for Improving Patient Safety. Developed by the VA NCPS, these are tools you can use to identify where errors can occur in the delivery of care and help you take corrective steps to avoid patient harm.

During the past two years, the AHA has encouraged hospitals and health systems to develop a culture of safety -- a culture that focuses on actively evaluating all aspects of care delivery in an effort to prevent errors. The Strategies for Leadership A Toolkit for Improving Patient Safety effectively does just that. The toolkit's focus is on helping hospitals prioritize and systematically evaluate aspects of care delivery that may be at high-risk for causing patient harm or have been associated with an adverse event or close call. These tools are to be used in two ways: prospectively -- before harm might occur, and retrospectively -- after a close call or harm occurs.

Proactive Risk Assessment. The VA-developed Healthcare Failure Mode and Effect Analysis (HFMEA) looks at a process, identifies where errors may occur and takes steps to eliminate or minimize future occurrences. The video, "Basics of Healthcare Failure Mode and Effects Analysis," explains the five-step HFMEA process. When performed properly, HFMEA meets the JCAHO Hospital Accreditation Manual leadership standard LD.5.2. In addition to the video, the toolkit includes a workbook featuring worksheets and diagrams to help your team prioritize potential risks to patients and assess interventions.

Root Cause Analysis. The Safety Assessment Code (SAC) Matrix helps hospitals prioritize adverse events and close calls based on both actual and potential outcomes. Incidents are assigned a severity category (catastrophic, major, moderate or minor) and a probability category (frequent, occasional, uncommon or remote). The resulting SAC score determines the incidents requiring a root cause analysis (RCA) thereby assisting hospitals in appropriately allocating patient safety resources. The VA NCPS Triage Cards help hospitals effectively deal with difficult tasks during an RCA. The cards are a series of questions that prompt your team to identify human factors and systems issues that may have contributed to a close call or adverse event.

The toolkit contains an instructional video on HFMEA a training CD-ROM for the SAC matrix and triage cards, a set of VA NCPS Triage Cards and workbooks for HFMEA and SAC.