VHA National Center for Patient Safety Home

<!doctype html> <html lang="en"> <head>  <meta charset="utf-8"> <meta name="author" content="US Department of Veterans Affairs, Veterans Health Administration, National Center for Patient Safety" /> <meta name="dcterms.subject" content="VA National Center for Patient Safety" /> <meta name="keywords" content="safety, falls, moderate sedation, cognitive aids, hazards, alerts, medications, errors, HFMEA, root cause, NCPS, VA National Center for Patient Safety, Patient Safety" /> <meta name="description" content="The NCPS was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. Our goal is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care. Patient safety managers at 151 VA hospitals and patient safety officers at 21 VA regional headquarters participate in the program. " /> <meta name="dcterms.created" content="20130815" /> <meta name="dcterms.dateAccepted" content="20231129" /> <meta name="dcterms.type" content="Program Homepage"> <meta http-equiv="X-UA-Compatible" content="IE=edge" />  <meta name="viewport" content="width=device-width, initial-scale=1.0" />  <title>VHA National Center for Patient Safety Home</title>  <link href="/va_files/2014/responsive/images/favicon.ico" media="all" rel="shortcut icon" type="image/x-icon"> <link href="/va_files/2014/responsive/styles/bootstrap.css" media="all" rel="stylesheet" type="text/css"> <link href="/va_files/2014/responsive/styles/layout.css" media="all" rel="stylesheet" type="text/css"> <link href="/va_files/2014/responsive/styles/accessibleMegaMenu.css" media="all" rel="stylesheet" type="text/css"> <link href="/va_files/2014/responsive/styles/health.css" media="all" rel="stylesheet" type="text/css"> <link href="/va_files/2014/responsive/styles/slider.css" media="all" rel="stylesheet" type="text/css"> <link href="/va_files/2014/responsive/styles/slide-menu-custom.css" media="all" rel="stylesheet" type="text/css"> <link href="/va_files/2014/responsive/styles/tabs.css" media="all" rel="stylesheet" type="text/css"> <link href="/va_files/2014/responsive/styles/modal.css" media="all" rel="stylesheet" type="text/css"> <link href="https://cdn.eo.va.gov/vendor/fa5/current/css/all.css" rel="stylesheet" type="text/css"/>       <script type="text/javascript" src="/va_files/2014/responsive/scripts/jquery-1-10-2.js"></script> <script type="text/javascript" src="/va_files/2014/responsive/scripts/swipe-min.js"></script> <script type="text/javascript" src="/va_files/2014/responsive/scripts/scrollable.js"></script> <script type="text/javascript" src="/va_files/2014/responsive/scripts/left-nav.js"></script> <script type="text/javascript" src="/va_files/2014/responsive/scripts/tabs-library.js"></script> <script type="text/javascript" src="/va_files/2014/responsive/scripts/tabs-accord.js"></script> <script type="text/javascript" src="/va_files/2014/responsive/scripts/accessible2.js"></script> <script type="text/javascript" src="/va_files/2014/responsive/scripts/custom.js"></script> <script src="/va_files/2014/responsive/scripts/externalLinks.js" type="text/javascript"></script> <script async type="text/javascript" src="https://dap.digitalgov.gov/Universal-Federated-Analytics-Min.js?agency=VA&yt=1&pga4=G-Y8BBTRX2M1" id="_fed_an_ua_tag"></script> <style type="text/css">.brand-consolidation-deprecated { display: none !important; } </style> <link rel="stylesheet" href="https://prod-va-gov-assets.s3-us-gov-west-1.amazonaws.com/generated/styleConsolidated.css" /> <script type="text/javascript" src="https://prod-va-gov-assets.s3-us-gov-west-1.amazonaws.com/generated/polyfills.entry.js"></script> <script type="text/javascript" src="https://prod-va-gov-assets.s3-us-gov-west-1.amazonaws.com/generated/vendor.entry.js"></script> <script type="text/javascript" src="https://prod-va-gov-assets.s3-us-gov-west-1.amazonaws.com/generated/proxy-rewrite.entry.js"></script> <script type="text/javascript" src="https://prod-va-gov-assets.s3-us-gov-west-1.amazonaws.com/js/vendor/uswds.min.js"></script>  <script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl+ '&gtm_auth=EVfhr6k93Fl16jzaZVCafQ&gtm_preview=env-2&gtm_cookies_win=x';f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-WZ6MXMD');</script>   <meta property="og:locale" content="en_US" /> <meta property="og:type" content="website" /> <meta content="https://www.va.gov/img/design/logo/va-og-image.png" property="og:image" /> <meta content="VA.gov | Veterans Affairs" property="og:title"> <meta content="VA.gov | Veterans Affairs" name="twitter:title"> <meta name="twitter:card" content="Summary" /> <meta name="twitter:site" content="@DeptVetAffairs" /> <meta content="Apply for and manage the VA benefits and services you鈥檝e earned as a Veteran, Servicemember, or family member鈥攍ike health care, disability, education, and more." property="og:description" /> <meta content="Apply for and manage the VA benefits and services you鈥檝e earned as a Veteran, Servicemember, or family member鈥攍ike health care, disability, education, and more." name="twitter:description" /> <meta content="Apply for and manage the VA benefits and services you鈥檝e earned as a Veteran, Servicemember, or family member鈥攍ike health care, disability, education, and more." name="description" /> <meta name="twitter:image" content="https://www.va.gov/img/design/logo/va-og-twitter-image.png" /> <style type="text/css" media="screen,print"> @import url(/PATIENTSAFETY/styles/site-styles.css); </style> <style type="text/css" media="screen,print"> @import url(/TS_SHARED/2014/responsive/va_administrations/VHA/styles/site-styles.css); </style> <script type="text/javascript"> var vaSurvey = 'mcenter'; var vaSiteFolder = 'PATIENTSAFETY'; </script> <script type="text/javascript" src="/TS_SHARED/2014/responsive/va_administrations/VHA/scripts/analytics-po.js"></script> <style type="text/css"> #tabContent { margin-bottom: 2em; } #homeinnerContent .widget { width: 100%; margin-left: 0px; } #homeinnerContent .widget-title { width: 94%; float: none; align: center; } .widget .threeCol { width: 30%; float: left; margin-right: 20px; margin-bottom: 20px; } #badgecontainer { text-align: justify; -ms-text-justify: distribute-all-lines; text-justify: distribute-all-lines; } #badgecontainer > div { vertical-align: top; display: inline-block; *display: inline; zoom: 1 } .stretch { width: 100%; display: inline-block; font-size: 0; line-height: 0 } </style> </head> <body> <div id="skiplink"> <a href="#main-content" >skip to page content</a></div>  <div id="main"> <div id="bg-main"> <div id="bg-middle-effect"> <div class="container" id="main-wrap"> <header class="row main-header-wrap"> <div class="csshide"> Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. </div> <div class="main-header clearfix">  <div id="locator-mobile"> <div class="va-crisis-line"> <div class="va-flex"> <button data-show="#modal-crisisline" class="va-crisis-line-button va-overlay-trigger"> <span class="va-flex"> <span class="vcl"></span>Get help from Veterans Crisis Line </span> </button> </div> </div> <div id="mainLocator-btn">Locator</div> <div id="mainContact-btn">Contact</div> <div class="search-btn" id="search-btn">Search</div> <div id="main-contact"> <div class="title">Contact Us</div> <p><a href="https://www.va.gov/contact-us/#explore-our-faqs-and-other-res">FAQs</a></p> <p><a href="https://www.va.gov/contact-us/#contact-us-online-through-ask-">Ask a Question</a></p> <p><a href="https://www.va.gov/contact-us/#call-us">Toll Free Numbers</a></p> </div> <div id="main-locator"> <div class="title">Locator</div> <p><a href="https://www.va.gov/directory/guide/division_flsh.asp?dnum=1">Hospitals and Clinics</a></p> <p><a href="https://www.va.gov/directory/guide/vetcenter_flsh.asp">Vet Centers</a></p> <p><a href="https://www.va.gov/directory/guide/division_flsh.asp?dnum=3">Regional Benefits Offices</a></p> <p><a href="https://www.benefits.va.gov/homeloans/contact_rlc_info.asp">Regional Loan Centers</a></p> <p><a href="https://www.va.gov/directory/guide/division_flsh.asp?dnum=4 ">Cemetery Locations</a></p> </div> </div>   <div class="social-n-search"> <div class="va-crisis-line"> <div class="va-flex"> <button data-show="#modal-crisisline" class="va-crisis-line-button va-overlay-trigger"> <span class="va-flex"> <span class="vcl"></span>Get help from Veterans Crisis Line </span> </button> </div> </div> <div class="search-btn">Search</div> <div id="main-search">  <div id="search-area"> <form id="searchForm" method="GET" action="https://www.va.gov/search/">  <div id="mainSearchForm"><label for="searchtxt" class="positionsearch">Enter your search text</label><input name="query" type="text" id="searchtxt" size="5" title="Enter your search text" value="" /><input name="t" type="hidden" value="false" /><label class="positionsearch" for="edit-submit">Button to start search</label><input id="edit-submit" class="form-submit" type="image" src="https://www.va.gov/va_files/2014/responsive/images/main-search-button.png" alt="Click here to submit your search" name="submit"></div> </form> </div>  </div>  <div id="main-social-wrapper"> <div class="social-wrapper-508"> <div id="main-secondary-nav"> <ul class="secondary-nav"> <li><a href="https://www.va.gov/site_map.htm" title="Site Map A-Z">site map [a-z]</a></li> </ul> </div> <div class="main-social-containers"><a title="Link to VA's Email Directory" href="https://public.govdelivery.com/accounts/USVA/subscriber/new/"><img src="https://www.va.gov/va_files/2014/responsive/images/social-email.png" alt="Email icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Facebook page" href="https://www.facebook.com/VeteransAffairs"><img src="https://www.va.gov/va_files/2014/responsive/images/social-fb.png" alt="Facebook icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Twitter account" href="https://www.twitter.com/DeptVetAffairs/"><img src="https://www.va.gov/va_files/2014/responsive/images/social-twitter.png" alt="Twitter icon"></a></div> <div class="main-social-containers"><a title="Link to VA News" href="https://news.va.gov"><img src="https://www.va.gov/va_files/2014/responsive/images/social-blog.png" alt="Blog icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Flickr account" href="https://www.flickr.com/photos/VeteransAffairs/"><img src="https://www.va.gov/va_files/2014/responsive/images/social-flickr.png" alt="Flickr icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Youtube account" href="https://www.youtube.com/user/DeptVetAffairs"><img src="https://www.va.gov/va_files/2014/responsive/images/social-youtube.png" alt="Youtube icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Instagram account" href="https://www.instagram.com/deptvetaffairs/"><img src="https://www.va.gov/va_files/2014/responsive/images/social-instagram.png" alt="Instagram icon"></a></div> </div> </div> </div>   <div id="main-logo"> <a href="https://www.va.gov" title="Go to VA.gov" class="logo"><img src="/va_files/2014/responsive/images/header-logo.png" alt="Official seal of the United States Department of Veterans Affairs"></a> </div>  </div>   <nav id="main-nav" class="main-nav"> <div id="menu-btn" class="menu-btn"> <div class="rt-menu"><span>More VA</span></div> </div>  <div id="nav-wrap"> <b id="close-nav"></b> <div class="menu-btn" id="menu-btn-close"> <div class="rt-menu"><span>More VA</span></div> </div> <div id="nav-container" class="nav-container-close"> <ol class="accessible-megamenu"> <li class="accessible-megamenu-top-nav-item">  <span class="mega-hdr-text"> <a href="https://www.va.gov/health" aria-haspopup="true">Health</a></span> <div class="cols-1 firstcol accessible-megamenu-panel"> <ol> <li class="accessible-megamenu-panel-group"> <ol> <li><a href="https://www.va.gov/health-care/">Health Care Information</a></li> <li><a href="https://www.va.gov/health/topics/">A-Z Health Topic Finder</a></li> <li><a href="https://www.myhealth.va.gov/">My Health<strong><em>e</em></strong>Vet</a></li> <li><a href="https://www.va.gov/health-care/refill-track-prescriptions">Prescriptions Refills</a></li> <li><a href="https://www.va.gov/health-care/schedule-view-va-appointments">Schedule a VA Appointment</a></li> <li><a href="https://www.veteranscrisisline.net/">Veterans Crisis Line</a></li> <li><a href="https://www.mentalhealth.va.gov/">Mental Health</a></li> <li><a href="https://www.ptsd.va.gov/">PTSD</a></li> <li><a href="https://www.publichealth.va.gov/">Public Health</a></li> <li><a href="https://www.va.gov/communitycare/">Community Care</a></li> <li><a href="https://www.caregiver.va.gov/">Caregiver Support </a></li> <li><a href="https://www.va.gov/resources/choosing-between-urgent-and-emergency-care/">Urgent Care </a></li> </ol> </li> </ol> </div> </li>  <li class="accessible-megamenu-top-nav-item">  <span class="mega-hdr-text"> <a href="https://www.benefits.va.gov/" aria-haspopup="true">Benefits</a></span> <div class="cols-1 accessible-megamenu-panel"> <ol> <li class="accessible-megamenu-panel-group"> <ol> <li><a href="https://www.benefits.va.gov/">General Benefits Information</a></li> <li><a href="https://www.benefits.va.gov/compensation/">Disability Compensation</a></li> <li><a href="https://www.benefits.va.gov/pension/">Pension</a></li> <li><a href="https://www.benefits.va.gov/gibill/">GI Bill <span class="registeredmark">®</span></a></li> <li><a href="https://www.benefits.va.gov/vocrehab/" >Vocational Rehabilitation & Employment</a></li> <li><a href="https://www.benefits.va.gov/gibill/survivor_dependent_assistance.asp">Dependents' Educational Assistance</a></li> <li><a href="https://www.va.gov/opa/persona/dependent_survivor.asp">Survivor Benefits</a></li> <li><a href="https://www.benefits.va.gov/homeloans/">Home Loans</a></li> <li><a href="https://www.benefits.va.gov/insurance/">Life Insurance</a></li> <li><a href="https://benefits.va.gov/benefits/appeals.asp">Appeals Modernization</a></li> </ol> </li> </ol> </div> </li>  <li class="accessible-megamenu-top-nav-item">  <span class="mega-hdr-text"> <a href="https://www.cem.va.gov/" aria-haspopup="true">Burials & Memorials</a></span> <div class="cols-1 accessible-megamenu-panel" > <ol> <li class="accessible-megamenu-panel-group"> <ol> <li><a href="https://www.cem.va.gov/">Cemetery Services</a></li> <li><a href="https://www.cem.va.gov/burial_benefits/">Burials</a></li> <li><a href="https://www.cem.va.gov/hmm/">Headstones Markers & Medallions</a></li> <li><a href="https://www.cem.va.gov/pmc.asp">Presidential Memorial Certificates</a></li> <li><a href="https://www.cem.va.gov/cems/listcem.asp">Cemeteries</a></li> <li><a href="https://gravelocator.cem.va.gov/">Nationwide Gravesite Locator</a></li> <li><a href="https://www.cem.va.gov/burial_benefits/burial_flags.asp">Burial Flags</a></li> <li><a href="https://www.cem.va.gov/burial_benefits/">Burial Allowance</a></li> </ol> </li> </ol> </div> </li>  <li class="accessible-megamenu-top-nav-item">  <span class="mega-hdr-text"><a href="https://www.va.gov/landing2_about.htm" aria-haspopup="true">About VA</a></span> <div class="cols-2 fifthtolast accessible-megamenu-panel"> <ol> <li class="accessible-megamenu-panel-group"> <span class="mega-hdr-sub-text"><span class="panelheader">Inside VA</span></span> <ol class="accessible-megamenu-lvl3"> <li><a href="https://www.va.gov/opa/bios/secva.asp">Secretary of VA</a></li> <li><a href="https://www.va.gov/opa/bios/">Executive Biographies</a></li> <li><a href="https://www.va.gov/landing_organizations.htm">Organizations</a></li> <li><a href="https://www.va.gov/about_va/vahistory.asp">History</a></li> </ol> </li> <li class="accessible-megamenu-panel-group"> <span class="mega-hdr-sub-text"><span class="panelheader">Budget and Performance</span></span> <ol class="accessible-megamenu-lvl3"> <li><a href="https://www.va.gov/performance/">VA Plans, Budget, & Performance</a></li> <li><a href="https://www.va.gov/finance/afr/index.asp">Agency Financial Report (AFR)</a></li> <li><a href="https://www.va.gov/budget/products.asp">Budget Submission</a></li> <li><a href="https://www.va.gov/recovery/">Recovery Act</a></li> </ol> </li> </ol> </div> </li> <li class="accessible-megamenu-top-nav-item"> <span class="mega-hdr-text"><a href="https://www.va.gov/landing_organizations.htm" aria-haspopup="true" aria-label="VA Resources">Resources</a></span> <div class="cols-1 accessible-megamenu-panel"> <ol> <li class="accessible-megamenu-panel-group"> <ol> <li><a href="https://www.va.gov/landing2_business.htm">Business</a></li> <li><a href="https://www.va.gov/oca/index.asp" >Congressional Affairs</a></li> <li><a href="https://www.va.gov/jobs/">Jobs</a></li> <li><a href="https://www.va.gov/opa/publications/benefits_book.asp">Benefits Booklet</a></li> <li><a href="https://www.va.gov/vetdata/">Data & Statistics</a></li> <li><a href="https://www.va.gov/data/">VA Open Data</a></li> <li><a href="https://mobile.va.gov/appstore/"> VA App Store</a></li> <li><a href="https://www.nrd.gov/">National Resource Directory</a></li> <li><a href="https://www.va.gov/ogc/recognizedvsos.asp">Veteran Service Organizations</a></li> <li><a href="https://www.va.gov/accountability/">Office of Accountability & Whistleblower Protection</a></li> <li><a href="https://www.va.gov/transparency/">Transparency</a></li> </ol> </li> </ol> </div> </li> <li class="accessible-megamenu-top-nav-item"> <span class="mega-hdr-text"><a href="https://www.va.gov/landing2_media_room.htm" aria-haspopup="true">Media Room</a></span> <div class="cols-3 thirdtolast accessible-megamenu-panel"> <ol> <li class="accessible-megamenu-panel-group"> <span class="mega-hdr-sub-text"><span class="panelheader">Inside the Media Room</span></span> <ol class="accessible-megamenu-lvl3"> <li><a href="https://www.va.gov/opa/">Public Affairs</a></li> <li><a href="https://www.va.gov/opa/pressrel/">News Releases</a></li> <li><a href="https://www.va.gov/opa/speeches/">Speeches</a></li> <li><a href="https://www.youtube.com/user/DeptVetAffairs">Videos</a></li> <li><a href="https://www.va.gov/opa/publications/">Publications</a></li> </ol> </li> <li class="accessible-megamenu-panel-group"> <span class="mega-hdr-sub-text"><span class="panelheader">National Observances</span></span> <ol class="accessible-megamenu-lvl3"> <li><a href="https://www.va.gov/opa/vetsday/">Veterans Day</a></li> <li><a href="https://www.va.gov/opa/speceven/memday/">Memorial Day</a></li> <li><a href="https://www.va.gov/opa/publications/celebrate_americas_freedoms.asp">Celebrating America's Freedoms</a></li> </ol> </li> <li class="accessible-megamenu-panel-group"> <span class="mega-hdr-sub-text"><span class="panelheader">Special Events</span></span> <ol class="accessible-megamenu-lvl3"> <li><a href="https://www.blogs.va.gov/nvspse/">Adaptive Sports Program</a></li> <li><a href="https://www.blogs.va.gov/nvspse/national-veterans-creative-arts-festival/">Creative Arts Festival</a></li> <li><a href="https://www.blogs.va.gov/nvspse/national-veterans-golden-age-games/">Golden Age Games</a></li> <li><a href="https://www.blogs.va.gov/nvspse/national-veterans-summer-sports-clinic/">Summer Sports Clinic</a></li> <li><a href="https://www.veteransgolfclinic.org/">Training - Exposure - Experience (TEE) Tournament</a></li> <li><a href="https://wheelchairgames.org/">Wheelchair Games</a></li> <li><a href="https://www.wintersportsclinic.org/">Winter Sports Clinic</a></li> </ol> </li> </ol> </div> </li> <li class="accessible-megamenu-top-nav-item"> <span class="mega-hdr-text"><a href="https://www.va.gov/landing2_locations.htm" aria-haspopup="true">Locations</a></span> <div class="cols-1 secondtolast accessible-megamenu-panel" > <ol> <li class="accessible-megamenu-panel-group"> <ol> <li><a href="https://www.va.gov/directory/guide/division.asp?dnum=1&isFlash=0">Hospitals & Clinics</a></li> <li><a href="https://www.va.gov/directory/guide/vetcenter.asp?isFlash=0">Vet Centers</a></li> <li><a href="https://www.va.gov/directory/guide/division.asp?dnum=3&isFlash=0">Regional Benefits Offices</a></li> <li><a href="https://www.benefits.va.gov/homeloans/contact_rlc_info.asp">Regional Loan Centers</a></li> <li><a href="https://www.va.gov/directory/guide/division.asp?dnum=4&isFlash=0">Cemetery Locations</a></li> </ol> </li> </ol> </div> </li> <li class="accessible-megamenu-top-nav-item last"> <span class="mega-hdr-text"><a href="https://www.va.gov/contact-us/" aria-haspopup="true">Contact Us</a></span> <div class="cols-1 last accessible-megamenu-panel" > <ol> <li class="accessible-megamenu-panel-group"> <ol> <li><a href="https://www.va.gov/contact-us/#explore-our-faqs-and-other-res">FAQs</a></li> <li><a href="https://www.va.gov/contact-us/#contact-us-online-through-ask-">Ask a Question</a></li> <li><a href="https://www.va.gov/contact-us/#call-us">Toll Free Numbers</a></li> </ol> </li> </ol> </div> </li> </ol> </div> </div>  </nav>  </header> <section class="row" id="container"> <div id="mainContentWrapper"> <a id="content-wrapper"></a>   <div id="breadCrumbPath"> <a href="https://www.va.gov/">VA</a> » <a href="https://www.va.gov/health">Health Care</a> » VHA National Center for Patient Safety </div>   <h1>VHA National Center for Patient Safety</h1>  </div>   <div class="col-md-3" id="left-bar-wrap" > <div class="fill">    <div id="leftNavContainer" class="clearfix">  <div class="sitemap" id="sitemapup"><span>Menu</span></div> <div id="leftNavWrap"> <div id="leftNav" class="lftNavhide"> <div class="sitemap" ><span>Menu</span></div> <ul class="accordion" style="margin-left:0px; padding-top:0px;">  <li><a href="https://www.va.gov/qualityandpatientsafety" title="Quality and Patient Safety" target="_blank">Quality and Patient Safety</a></li> <li><a href="#" title="Patient Safety"><span></span>Patient Safety</a> <ul class="sub-menu"> <li><a href="/index.asp" title="NCPS Home">NCPS Home</a></li> <li><a href="#" title="Veterans"><span></span>Veterans</a> <ul class="sub-sub-menu"> <li><a href="#" title="VA Care is Safe" target="_blank"><span></span>VA Care is Safe</a> <ul class="sub-sub-menu"> <li><a href="/veterans/safe.asp" title="VA Care is Safe">VA Care is Safe</a></li> <li><a href="/veterans/surgery.asp" title="Ensuring Correct Surgery">Ensuring Correct Surgery</a></li> <li><a href="/veterans/get_involved.asp" title="Get Involved!">Get Involved!</a></li> <li><a href="/veterans/oxygen.asp" title="Home Oxygen Safety">Home Oxygen Safety</a></li> <li><a href="/veterans/medication.asp" title="Medication Safety">Medication Safety</a></li> <li><a href="/professionals/stop-the-line.asp" title="Stop The Line" target="_blank">Stop The Line</a></li> </ul> <li><a href="https://www.qualityandsafety.va.gov/" title="VA Care is High-Quality"><span></span>VA Care is High-Quality</a> <ul class="sub-sub-menu"> <li><a href="https://www.patientsafety.va.gov/veterans/quality.asp" title="VA Care is High-Quality">VA Care is High-Quality</a></li> <li><a href="https://www.accesstocare.va.gov/ " title="VA Access & Quality" target="_blank">VA Access & Quality</a></li> <li><a href="https://www.patientsafety.va.gov/veterans/infections.asp" title="Infections">Infections</a></li> </ul> <li><a href="https://www.va.gov/patientcenteredcare/" title="VA Care is Patient-Centered"><span></span>VA Care is Patient-Centered</a> <ul class="sub-sub-menu"> <li><a href="https://www.patientsafety.va.gov/veterans/patient-centered.asp" title="VA Care is Patient-Centered">VA Care is Patient-Centered</a></li> <li><a href="https://www.patientsafety.va.gov/veterans/wandering.asp" title="Patients at Risk for Wandering">Patients at Risk for Wandering</a></li> <li><a href="https://www.patientsafety.va.gov/veterans/falls.asp" title="Preventing Falls">Preventing Falls</a></li> <li><a href="https://www.patientsafety.va.gov/veterans/dailyplan.asp" title="The Daily Plan">The Daily Plan</a></li> <li><a href="https://www.patientsafety.va.gov/veterans/discharge.asp" title="What to Do After Discharge">What to Do After Discharge</a></li> </ul> <li><a href="https://www.patientsafety.va.gov/veterans/resources.asp" title="Veteran Resources"><span></span>Veteran Resources</a> <ul class="sub-sub-menu"> <li><a href="https://www.patientsafety.va.gov/veterans/resources.asp" title="Veteran and Family Resources">Veteran and Family Resources</a></li> </ul> </ul> <li><a href="#" title="Medical Professionals"><span></span>Medical Professionals</a> <ul class="sub-sub-menu"> <li><a href="/professionals/index.asp" title="For Medical Professionals">For Medical Professionals</a></li> <li><a href="/professionals/alerts/index.asp" title="Alerts and Advisories">Alerts and Advisories</a></li> <li><a href="#" title="Hazard Summaries"><span></span>Hazard Summaries</a> <ul class="sub-sub-menu"> <li><a href="/professionals/hazards/anticoag.asp" title="Anticoagulation Vulnerability">Anticoagulation Vulnerability</a></li> <li><a href="/professionals/hazards/glucometer.asp" title="Glucometers">Glucometers</a></li> <li><a href="/professionals/hazards/heater_cooler.asp" title="Heater Cooler Devices">Heater Cooler Devices</a></li> <li><a href="/professionals/hazards/mr.asp" title="Magnetic Resonance">Magnetic Resonance</a></li> <li><a href="/professionals/hazards/oxygen.asp" title="Oxygen (Compressed Gas)">Oxygen (Compressed Gas)</a></li> </ul> <li><a href="#" title="On the Job Tools"><span></span>On the Job Tools</a> <ul class="sub-sub-menu"> <li><a href="/professionals/onthejob/falls.asp" title="Falls Toolkit">Falls Toolkit</a></li> <li><a href="/A_Toolkit_Patients_At_Risk_for_Wandering.asp" title="Wandering Reduction Toolkit">Wandering Reduction Toolkit</a></li> <li><a href="/professionals/onthejob/sedation.asp" title="Moderate Sedation Toolkit">Moderate Sedation Toolkit</a></li> <li><a href="/professionals/onthejob/cognitive.asp" title="Cognitive Aids">Cognitive Aids</a></li> <li><a href="/professionals/onthejob/surgery.asp" title="Ensuring Correct Surgery">Ensuring Correct Surgery</a></li> <li><a href="/professionals/onthejob/rca.asp" title="Root Cause Analysis (RCA)">Root Cause Analysis (RCA)</a></li> <li><a href="/professionals/onthejob/HFMEA.asp" title="HFMEA">HFMEA</a></li> <li><a href="/professionals/onthejob/hands.asp" title="Hand Hygiene">Hand Hygiene</a></li> <li><a href="/professionals/onthejob/assessment.asp" title="Patient Safety Assessment Tool">Patient Safety Assessment Tool</a></li> <li><a href="/professionals/onthejob/mentalhealth.asp" title="Mental Health Environment of Care">Mental Health Environment of Care</a></li> <li><a href="/professionals/onthejob/insulin.asp" title="U-500 Insulin">U-500 Insulin</a></li> <li><a href="/professionals/onthejob/dailyplan.asp" title="The Daily Plan®">The Daily Plan®</a></li> </ul> <li><a href="#" title="Training Programs"><span></span>Training Programs</a> <ul class="sub-sub-menu"> <li><a href="/professionals/training/chief-resident-program.asp" title="Chief Resident Program">Chief Resident Program</a></li> <li><a href="/professionals/training/team.asp" title="Clinical Team Training">Clinical Team Training</a></li> <li><a href="/professionals/training/curriculum.asp" title="Patient Safety Curriculum Workshop">Patient Safety Curriculum Workshop</a></li> <li><a href="/professionals/training/fellows.asp" title="Advanced Fellowship in Patient Safety">Advanced Fellowship in Patient Safety</a></li> </ul> <li><a href="#" title="Publications and Resources"><span></span>Publications and Resources</a> <ul class="sub-sub-menu"> <li><a href="/professionals/publications/newsletter.asp" title="TIPS Newsletter">TIPS Newsletter</a></li> <li><a href="/podcasts.asp" title="Patient Safety Podcast">Patient Safety Podcast</a></li> <li><a href="/professionals/publications/handbook.asp" title="NCPS Patient Safety Improvement Handbook">NCPS Patient Safety Improvement Handbook</a></li> <li><a href="/professionals/publications/glossary.asp" title="Glossary">Glossary</a></li> <li><a href="/professionals/publications/CLOUT.asp" title="Clinical Limits of Use Tools (CLOUT)">Clinical Limits of Use Tools (CLOUT)</a></li> <li><a href="/professionals/publications/resources.asp" title="Resources">Resources</a></li> </ul> <li><a href="/professionals/centers.asp" title="Patient Safety Centers of Inquiry">Patient Safety Centers of Inquiry</a></li> </ul> <li><a href="/safety-notice/philips-cpap-recall.asp" title="Philips CPAP Recall">Philips CPAP Recall</a></li> <li><a href="/professionals/stop-the-line.asp" title="Stop the Line">Stop the Line</a></li> <li><a href="#" title="About NCPS"><span></span>About NCPS</a> <ul class="sub-sub-menu"> <li><a href="/about/index.asp" title="About the National Center for Patient Safety">About the National Center for Patient Safety</a></li> <li><a href="/about/approach.asp" title="VA's Approach to Patient Safety">VA's Approach to Patient Safety</a></li> <li><a href="/about/organization.asp" title="Our Organization">Our Organization</a></li> <li><a href="/about/jobs.asp" title="Job Opportunities">Job Opportunities</a></li> <li><a href="/about/faqs.asp" title="Frequently Asked Questions">Frequently Asked Questions</a></li> </ul> <li><a href="/media/factsheets.asp" title="Fact Sheets">Fact Sheets</a></li> <li><a href="/ncps-symposium.asp" title="NCPS Symposium">NCPS Symposium</a></li> </ul>  <li><a href="#"><span></span>More Health Care</a> <ul class="sub-menu"> <li><a href="https://www.va.gov/health/index.asp">Veterans Health Administration</a></li> <li><a href="#"><span></span>Health Benefits</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/health-care/">Health Benefits Home</a></li> <li><a href="#"><span></span>Apply for VA Care</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/health-care/how-to-apply/">Apply Online</a></li> <li><a href="https://www.va.gov/health-care/eligibility/">Veteran Eligibility</a></li> <li><a href="https://www.va.gov/healthbenefits/apply/active_duty.asp">Active Duty</a></li> <li><a href="https://www.va.gov/health-care/family-caregiver-benefits/">Families of Veterans</a></li> <li><a href="https://www.va.gov/health-care/health-needs-conditions/womens-health-needs/">Women Veterans</a></li> </ul> </li> <li><a href="#"><span></span>Determine Costs</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/communitycare/revenue_ops/copays.asp">Copays</a></li> <li><a href="https://www.va.gov/healthbenefits/cost/financial_assessment.asp">Means Test</a></li> <li><a href="https://www.va.gov/health-care/about-va-health-benefits/va-health-care-and-other-insurance/">Health Insurance</a></li> <li><a href="https://www.va.gov/healthbenefits/cost/make_a_payment.asp">Make a Payment</a></li> </ul> </li> <li><a href="#"><span></span>Community Care</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/communitycare/">Community Care Home</a></li> <li><a href="https://www.va.gov/communitycare/programs/veterans/index.asp">For Veterans</a></li> <li><a href="https://www.va.gov/communitycare/providers/index.asp">For Providers</a></li> <li><a href="https://www.va.gov/communitycare/pubs/index.asp">Forms & Publications</a></li> </ul> </li> <li><a href="#"><span></span>Affordable Care Act</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/health/aca/index.asp">Overview</a></li> <li><a href="https://www.va.gov/health/aca/EnrolledVeterans.asp">Veterans Enrolled<br>in VA Health Care</a></li> <li><a href="https://www.va.gov/health/aca/NonEnrolledVeterans.asp">Veterans Not Enrolled in VA<br>Health Care</a></li> <li><a href="https://www.va.gov/health/aca/FamilyMembers.asp">Family Members</a></li> <li><a href="https://www.va.gov/health/aca/FAQ.asp">Frequently Asked Questions</a></li> </ul> </li> <li><a href="https://www.va.gov/health-care/schedule-view-va-appointments/">Schedule a VA Appointment</a></li> <li><a href="https://www.caregiver.va.gov/">Caregiver Support</a></li> <li><a href="https://www.va.gov/resources/choosing-between-urgent-and-emergency-care/">Urgent Care</a></li> </ul> </li> <li><a href="#"><span></span>Conditions & Treatments</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/health/topics/index.asp">See All Conditions & Treatments (A-Z)</a></li> <li><a href="https://www.hepatitis.va.gov/">Hepatitis</a></li> <li><a href="https://www.hiv.va.gov/">HIV</a></li> <li><a href="#"><span></span>Mental Health</a> <ul class="sub-sub-menu"> <li><a href="https://www.mentalhealth.va.gov/">Mental Health Home</a></li> <li><a href="https://www.mentalhealth.va.gov/suicide_prevention/index.asp">Suicide Prevention</a></li> <li><a href="https://www.mentalhealth.va.gov/substance-abuse/index.asp">Substance Abuse</a></li> <li><a href="https://www.mentalhealth.va.gov/msthome/index.asp">Military Sexual Trauma</a></li> <li><a href="https://www.ptsd.va.gov/">PTSD</a></li> <li><a href="https://www.mirecc.va.gov/">Research (MIRECC)</a></li> </ul> </li> <li><a href="https://www.publichealth.va.gov/exposures/index.asp">Military Exposures</a></li> <li><a href="https://www.polytrauma.va.gov/">Polytrauma</a></li> <li><a href="https://www.patientcare.va.gov/RehabilitationServices.asp">Rehabilitation</a></li> <li><a href="https://www.sci.va.gov/">Spinal Cord Injury</a></li> <li><a href="https://www.telehealth.va.gov/">Telehealth</a></li> <li><a href="https://www.womenshealth.va.gov/">Womens Health Issues</a></li> </ul> </li> <li><a href="#"><span></span>Wellness Programs</a> <ul class="sub-sub-menu"> <li><a href="https://www.myhealth.va.gov/mhv-portal-web/home">MyHealtheVet</a></li> <li><a href="https://www.nutrition.va.gov/">Nutrition</a></li> <li><a href="https://www.mentalhealth.va.gov/quit-tobacco/">Quitting Smoking</a></li> <li><a href="https://www.publichealth.va.gov/vaccines.asp">Vaccines & Immunizations</a></li> <li><a href="https://www.publichealth.va.gov/flu/index.asp">Flu Vaccination</a></li> <li><a href="https://www.prevention.va.gov/">Prevention / Wellness</a></li> <li><a href="https://www.publichealth.va.gov/">Public Health</a></li> <li><a href="https://www.move.va.gov/">Weight Management (MOVE!)</a></li> <li><a href="https://www.va.gov/wholehealth/">Whole Health Program</a></li> </ul> </li> <li><a href="#"><span></span>Locations</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/find-locations/?facilityType=health">Hospitals & Clinics</a></li> <li><a href="https://www.va.gov/find-locations/?facilityType=vet_center">Vet Centers</a></li> <li><a href="https://www.vacanteen.va.gov/">Veterans Canteen Service (VCS)</a></li> </ul> </li> <li><a href="#"><span></span>Research</a> <ul class="sub-sub-menu"> <li><a href="https://www.research.va.gov/">Research Home</a></li> <li><a href="https://www.research.va.gov/about/">About VA Research</a></li> <li><a href="https://www.research.va.gov/services/">Services</a></li> <li><a href="https://www.research.va.gov/programs/">Programs</a></li> <li><a href="https://www.research.va.gov/currents/">News, Events and Media</a></li> <li><a href="https://www.research.va.gov/topics/">Research Topics</a></li> <li><a href="https://www.research.va.gov/for_veterans/">For Veterans</a></li> <li><a href="https://www.research.va.gov/resources/">For Researchers</a></li> <li><a href="https://www.va.gov/oro/">Research Oversight</a></li> </ul> </li> <li><a href="#"><span></span>Special Groups</a> <ul class="sub-sub-menu"> <li><a href="https://www.caregiver.va.gov/">Caregivers</a></li> <li><a href="#"><span></span>Combat Veterans & their Families</a> <ul class="sub-sub-menu"> <li><a href="https://www.vetcenter.va.gov/">Readjustment Counseling (Vet Centers)</a></li> <li><a href="https://www.warrelatedillness.va.gov/">War Related Illness & Injury Study Center</a></li> </ul> </li> <li><a href="https://www.va.gov/homeless/">Homeless Veterans</a></li> <li><a href="https://www.oefoif.va.gov/">Returning Service Members</a></li> <li><a href="https://www.ruralhealth.va.gov/">Rural Veterans</a></li> <li><a href="https://www.va.gov/geriatrics/">Seniors & Aging Veterans</a></li> <li><a href="https://www.volunteer.va.gov/">Volunteers</a></li> <li><a href="https://www.womenshealth.va.gov/">Women Veterans</a></li> </ul> </li> <li><a href="#"><span></span>Careers, Job Help & Training</a> <ul class="sub-sub-menu"> <li><a href="#"><span></span>Find a Job with VA</a> <ul class="sub-sub-menu"> <li><a href="https://www.vacareers.va.gov/">Health Care Jobs (VA Careers)</a></li> <li><a href="https://www.va.gov/nursing/">Travel Nurses</a></li> </ul> </li> <li><a href="#"><span></span>Get Job Help</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/vetsinworkplace/">Vets in the Workplace</a></li> <li><a href="https://www.vaforvets.va.gov/">VA for Vets</a></li> <li><a href="https://www.va.gov/pbi/">Performance Based Interviewing</a></li> </ul> </li> <li><a href="https://www.va.gov/oaa/index.asp">Clinical Trainees (Academic Affiliations)</a> </li> <li><a href="#"><span></span>Employees & Contractors</a> <ul class="sub-sub-menu"> <li><a href="https://www.tms.va.gov/SecureAuth35/">Talent Management System (TMS)</a></li> <li><a href="https://www.valu.va.gov/Home/Index">VA Learning University (VALU)</a></li> <li><a href="https://www.simlearn.va.gov/">SimLearn</a></li> <li><a href="https://www.va.gov/library/valnet/index.asp">Libraries (VALNET)</a></li> </ul> </li> <li><a href="https://www.va.gov/vdl/">VA Software Documentation Library (VDL)</a></li> </ul> </li> <li><a href="#"><span></span>About VHA</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/health/aboutVHA.asp">Learn about VHA</a></li> <li><a href="https://www.va.gov/vhapublications/">Forms & Publications</a></li> <li><a href="#"><span></span>Quality & Safety</a> <ul class="sub-sub-menu"> <li><a href="https://www.accesstocare.va.gov/">Access and Quality Data</a></li> <li><a href="https://www.ethics.va.gov/">Ethics</a></li> <li><a href="https://www.healthquality.va.gov/">VA/DOD Clinical Practice Guidelines</a></li> <li><a href="https://www.va.gov/health/medicalinspector/">Medical Inspector</a></li> <li><a href="https://www.patientsafety.va.gov/">Patient Safety</a></li> </ul> </li> <li><a href="#"><span></span>Organizations</a> <ul class="sub-sub-menu"> <li><a href="https://www.va.gov/health/landing_admin.asp">Administrative</a></li> <li><a href="https://www.va.gov/health/landing_clinical.asp">Clinical</a></li> </ul> </li> </ul> </li> </ul> </li>  </ul> </div>  </div>  <div id="left-col-content">  <div class="widget clearfix"> <div class="widget-title"><span class="hdr-text">Quick Links </span></div> <div id="widget-quick-links"> <div id="widget-locator"> <div id="locator-form"> <script language="javascript" type="text/javascript"> var address = ""; var url = ""; function Validate() { var addr=trim(document.zipSearch.inputaddress.value); if (addr.length==0 || addr.toLowerCase()=="zip code"){ alert("Please enter Zip code."); document.zipSearch.inputaddress.focus(); return false; } else { address = trim(document.zipSearch.inputaddress.value); pgname = "https://www.va.gov/find-locations/"; url = pgname + "?address=" + address + "&page=1&facilityType=health&serviceType"; window.location.href=url; return false; } } function trim(str) { var re = /^\s+(.*?)\s+$/; return str.replace(re,"$1"); } </script> <form name="zipSearch" action="https://www.va.gov/find-locations/" method="get" onSubmit="return Validate();"> <label for="LocatorPostalCode" class="positionset">Enter ZIP code here</label> <input id="LocatorPostalCode" class="inputstyle" type="text" onFocus="this.value=''" size="10" maxlength="10" value="Zip Code" name="inputaddress" title="Enter ZIP here"> <div id="zipButton"> <label for="zipInputButton" class="positionset">Enter ZIP code here</label> <input id="zipInputButton" type="image" src="/va_files/2012/images/button-locator.png" alt="Search" title="Click here to submit"><input type="submit" id="submit-hidethis" class="hidethis" value="Search" /> </div>  </form> </div>  <ul> <li><a title="Heath Programs" href="https://www.va.gov/health/programs/index.asp"><img src="https://www.va.gov/health/images/homepage/button-health.png" alt="Health Programs"></a></li> <li><a title="Public Health Issues" href="https://www.publichealth.va.gov/"><img src="https://www.va.gov/health/images/homepage/button-protect-your-health.png" alt="Protect your health"></a></li> <li><a title="A-Z Health Topics Index" href="https://www.va.gov/health/topics/index.asp"><img src="https://www.va.gov/health/images/homepage/button-health-a-z.png" alt="Learn more: A-Z Health"></a></li> </ul> </div> </div> </div>   <div class="clearfix"></div>  <div class="badge"><a href="https://www.veteranscrisisline.net/"><img src="https://www.va.gov/health/images/homepage/badge_VCL.jpg" width="184" height="90" title="Veterans Crisis Line Badge" alt="Veterans Crisis Line Badge"></a></div> <div class="badge"><a href="https://www.myhealth.va.gov/mhv-portal-web/home"><img src="https://www.va.gov/health/images/homepage/badge_MHEV.jpg" width="184" height="90" title="My healthevet badge" alt="My healthevet badge" ></a></div>  </div>  <style> .va-footer-links-bottom:last-of-type { margin-bottom: 20px; } #footer-alert { position: fixed; bottom: 0; left:0; z-index:1; width: 100%; height: 60px; background-color: #f1f1f1; } #footer-alert p { margin: 8px auto; text-align: center; font-size: 16px; font-weight: 700; color: #004795; } #footer-alert p a { color: #004795; } .va-banner-body > p > i { display: none; } @media (min-width: 480px) { .va-banner-body > p > i { display: inline-block; background-color: #ffffff; border-radius: 50%; margin: 0.4rem; padding: 0.8em; } #footer-alert p { margin: 5px auto; font-size: 1.2em; } } </style> <script> $(function() { document.getElementById("sub-footer").style.marginBottom = "60px"; var alertMsg = "<div id=\"footer-alert\"><div class=\"va-banner-body\" role=\"banner\"><p><i class=\"fas fa-bullhorn icon-left\" aria-hidden=\"true\"> </i><a href=\"https://www.va.gov/resources/the-pact-act-and-your-va-benefits\" title=\"PACT Act and your VA benefits\">Learn what the PACT Act means for your VA benefits <i class=\"fas fa-angle-double-right\" aria-hidden=\"true\"></i><\/a><\/p><\/div><\/div>"; $("body").append(alertMsg); }); </script> </div>    </div> </div>  <div class="col-md-9">   <div class="fill">  <div id="healthslider" class="slider2 slider"> <a class="prev"><img src="/va_files/2014/responsive/images/arrow-left.png" alt="previous slide" title="previous slide"/></a> <div id="slider-controls"> <a href="#" id="pause" tabindex="-1"><img width="20" height="20" id="pause1" alt="Pause" src="/va_files/2014/responsive/images/bt_pause_s2.png"></a> <a href="#" id="play" tabindex="-1"><img width="20" height="20" id="play1" alt="Play" src="/va_files/2014/responsive/images/bt_play_s2.png"></a> </div> <div class="scrollable"> <div class="items">  <div class="slide"> <a href="/veterans/safe.asp" tabindex="-1"> <img src="/images/slider/mh_checklist_banner.jpg" alt="Three clinicians review a patient's chart." title="VA Care is Safe" /> </a> <div class="slider-info"> <h3>VA Care is Safe</h3> <p>VA health care is as safe or safer when compared to care received outside of the VA.</p> <p><a tabindex="-1" href="/veterans/safe.asp">Learn more »</a></p> </div> </div> <div class="slide"> <a href="/index.asp" tabindex="-1"> <img src="/images/slider/banner_5.jpg" alt="A physician looks while those behind him look at a chart. " title="VA Care is High Quality" /> </a> <div class="slider-info"> <h3>VA Care is High Quality</h3> <p>VA strives to provide the highest quality care possible every day.</p> <p><a tabindex="-1" href="/index.asp">Learn more »</a></p> </div> </div> <div class="slide"> <a href="https://www.patientsafety.va.gov/veterans/dailyplan.asp" tabindex="-1"> <img src="/images/slider/nurse_with_pt_banner.jpg" alt="A nurse sits with a patient." title="VA Care is Patient-Centered" /> </a> <div class="slider-info"> <h3>VA Care is Patient-Centered</h3> <p>VA aims to put the Veteran at the center of their care and give them the tools necessary to achieve the desired outcomes. </p> <p><a tabindex="-1" href="https://www.patientsafety.va.gov/veterans/dailyplan.asp">Learn more »</a></p> </div> </div> </div> </div> <a class="next"><img title="next slide" alt="next slide" src="/va_files/2014/responsive/images/arrow-right.png"></a>  <div class="slider-thumbnails"> <div class="thumbnails-wrap"> <a class="selected" target="_self" href=""> <span>VA Care is Safe</span> </a> <a class="" target="_self" href=""> <span>VA Care is High Quality</span> </a> <a class="" target="_self" href=""> <span>VA is Patient-Centered</span> </a> </div> </div> </div> </div>   <div class="row"> <div class="col-md-8"> <span style="position:absolute;"><a id="main-content"> </a></span> <div id="homeinnerContent">  <style></style> <h2>About Us</h2> <p>The National Center for Patient Safety (NCPS) promotes best practices for safe patient care and optimal patient care utilization throughout the organization. Accordingly, NCPS guides the VHA and external stakeholders on policies and strategies to do the following:</p> <ul class="ncps-list-general"> <li>Measure and mitigate harm to the Veteran and those who support their care;</li> <li>Track utilization and address deficient patient admission and discharge practice;</li> <li>Model characteristics of a High Reliability Organization including promotion of clinical team training and a just and safe culture; and</li> <li>Evaluation of healthcare solutions, technology, and innovations from a patient safety and value-based perspective.</li> </ul> <p>Patient safety managers at VA medical centers and patient safety officers at 18 VISNs participate in the program.</p>  <h2>The following program offices report to NCPS:</h2> <dl> <dt>Optimizing Health Care Value Program (OHVP)</dt> <dd>performs independent assessments and analyses on healthcare solutions to include technology, programs, processes and services to ensure they are effective and meet the needs of the organization.</dd> <dt>Utilization Management (UM)</dt> <dd>provides vital tools to manage quality and resources. The program provides consultation services and evidence-based practices to ensure Veterans receive the right care, in the right setting, at the right time, for the right clinical reasons.</dd> </dl>   </div> </div> <div class="col-md-4"> <div class="fill"> <div id="rightContent"> <div id="tier4RightContent"> <div id="innerRightContent">  <div class="clear"></div> <div class="widget clearfix"> <div class="widget-title"><h4>Resources</h4></div> <ul> <li><a href="/media/factsheets.asp" title="About NCPS">About NCPS</a></li> <li><a href="/professionals/training/team.asp" title="Clinical Team Training ">Clinical Team Training </a></li> <li><a href="/professionals/onthejob/cognitive.asp" title="Cognitive Aids">Cognitive Aids</a></li> <li><a href="/professionals/onthejob/falls.asp" title="Falls Toolkit">Falls Toolkit</a></li> <li><a href="/professionals/onthejob/hfmea.asp" title="HFMEA">HFMEA</a></li> <li><a href="https://www.patientsafety.va.gov/veterans/medication.asp" title="Medication Safety">Medication Safety</a></li> <li><a href="http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp" title="Mental Health Checklist">Mental Health Checklist</a></li> <li><a href="https://www.patientsafety.va.gov/podcasts.asp" title="Patient Safety Huddle Podcast">Patient Safety Huddle Podcast</a></li> <li><a href="/professionals/onthejob/rca.asp" title="Root Cause Analysis">Root Cause Analysis</a></li> <li><a href="/professionals/stop-the-line.asp" title="Stop the Line">Stop the Line</a></li> </ul> </div>   <div class="clear"></div> <div class="widget clearfix"> <div class="widget-title"><h4>Connect with VHA</h4></div> <div id="widget-social"> <div class="widget-social-col-l"> <ul> <li><a title="VHA on Facebook" href="https://www.facebook.com/VeteransHealth"><img src="/TS_SHARED/va_administrations/VHA/VAMC/images/social-icon-facebook-widget-2x.png" alt="Facebook"></a></li> <li><a title="VHA on YouTube" href="https://www.youtube.com/user/VeteransHealthAdmin"><img src="/TS_SHARED/va_administrations/VHA/VAMC/images/social-icon-youtube-widget-2x.png" alt="Youtube"></a></li> </ul> </div> <div class="widget-social-col-r"> <ul> <li><a title="VHA on Twitter" href="https://twitter.com/VeteransHealth"><img src="/TS_SHARED/va_administrations/VHA/VAMC/images/social-icon-twitter-widget-2x.png" alt="Twitter"></a></li> <li><a title="Health stories on VAntage Point blog" href="https://news.va.gov/category/health/"><img src="/TS_SHARED/va_administrations/VHA/VAMC/images/social-icon-blog-widget-2x.png" alt="Blog"></a></li> </ul> </div> </div> <div id="widget-email"> Subscribe to Receive<br> Email Updates <form action="https://public.govdelivery.com/accounts/USVHA/subscribers/qualify"> <input id="category_id" name="category_id" type="hidden" value="USVHA_C4"> <label for="email" class="sr-only"> <img alt="Required" class="required" src="https://public.govdelivery.com/images/required.gif?1215719772" />Button to subscribe to email </label> <input id="email" class="inputstyle" type="text" title="enter email here" onfocus="this.value=''" value="Email Address" size="10" name="email"> <div id="widget-email-Button"> <label for="form_button" class="sr-only">Button to subscribe to email</label> <input class="form_button" name="commit" type="image" src="/va_files/2012/images/button-footer-email.png" alt="subscribe" value="Submit" title="Click here to submit your email"> </div> </form> </div> <div class="clear"></div> <div class="clear"></div> </div>  </div> </div> </div> </div> </div> </div>  </div> </section> </div> </div> </div>  <div id="footer-effect"> <div class="container" id="footer"> <div class="row"> <div class="VHA-administration-logo"><img src="/TS_SHARED/va_administrations/VHA/VAMC/images/homepage/vha-excellence.png" height="46" width="198" alt="VHA Excellence"></div> <div class="footer-accordion"> <div class="col connect"> <span class="blue-hdr top-level"><a href="javascript:void(0)">CONNECT</a></span> <div id="connect" class="ftrcls"> <p class="mobile--hide"> <a href="https://www.veteranscrisisline.net/">Veterans Crisis Line:</a><br> <span class="larger"><a href="tel:+988">Call: 988</a></span> (Press 1)</p> <p class="h4correct">Social Media</p> <div id="footer-social-wrapper"> <div class="main-social-containers"><a title="Link to VA's Email Directory" href="https://public.govdelivery.com/accounts/USVA/subscriber/new/"><img src="/va_files/2014/responsive/images/social-email.png" alt="Email icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Facebook page" href="https://www.facebook.com/VeteransAffairs"><img src="/va_files/2014/responsive/images/social-fb.png" alt="Facebook icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Twitter account" href="https://www.twitter.com/DeptVetAffairs/"><img src="/va_files/2014/responsive/images/social-twitter.png" alt="Twitter icon"></a></div> <div class="main-social-containers"><a title="Link to VA News" href="https://news.va.gov"><img src="/va_files/2014/responsive/images/social-blog.png" alt="Blog icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Flickr account" href="https://www.flickr.com/photos/VeteransAffairs/"><img src="/va_files/2014/responsive/images/social-flickr.png" alt="Flickr icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Youtube account" href="https://www.youtube.com/user/DeptVetAffairs"><img src="/va_files/2014/responsive/images/social-youtube.png" alt="Youtube icon"></a></div> <div class="main-social-containers"><a title="Link to VA's main Instagram account" href="https://www.instagram.com/deptvetaffairs/"><img src="/va_files/2014/responsive/images/social-instagram.png" alt="Instagram icon"></a></div> </div>  <p class="h4correct"><a href="https://www.va.gov/opa/socialmedia.asp" title="The complete social media directory for the Department of Veterans Affairs" >Complete Directory </a></p> <div class="social-ft"> <span class="blue-hdr">EMAIL UPDATES</span> <div id="footer-email"> <form action="https://public.govdelivery.com/accounts/USVA/subscribers/qualify" onSubmit="return window.confirm("You are submitting information to an external page.\nAre you sure?");"> <input name="topic_id" type="hidden" value="USVA"> <label class="positionset" for="email_footer">Email Address Required</label> <input class="email_footer" id="email_footer" name="email" type="text" size="10" value="Email Address" onFocus="this.value=''" title="Enter here"> <div id="footer-email-Button"> <label class="positionset" for="commit">Button to subscribe to email</label> <input name="commit" class="form_button" id="commit" type="image" src="/va_files/2014/responsive/images/button-footer-email.png" alt="Click here to submit your email" title="Click here to submit your email"> </div> </form> </div> </div> </div> </div> <div class="col"> <span class="blue-hdr top-level"><a href="javascript:void(0)">VA HOME</a></span> <div class="ftrcls"> <ul> <li><a href="https://www.va.gov/about_va/va_notices.asp" >Notices</a></li> <li><a href="https://www.va.gov/privacy/" >Privacy</a></li> <li><a href="https://www.va.gov/foia/" >FOIA</a></li> <li><a href="https://www.va.gov/orpm/" >Regulations</a></li> <li><a href="https://www.va.gov/webpolicylinks.asp" >Web Policies</a></li> <li><a href="https://www.va.gov/orm/NOFEAR_Select.asp" >No FEAR Act</a></li> <li><a href="https://www.va.gov/accountability/" >Whistleblower Rights & Protections</a></li> <li><a href="https://www.va.gov/general/site_map.htm" >Site Index</a></li> <li><a href="https://www.usa.gov/" >USA.gov</a></li> <li><a href="https://www.whitehouse.gov/" >White House</a></li> <li><a href="https://www.va.gov/oig/" >Inspector General</a></li> </ul> </div> </div>  <div class="col"> <span class="blue-hdr top-level"><a href="javascript:void(0)">QUICK LIST</a></span> <div class="ftrcls"> <ul> <li><a href="https://www.benefits.va.gov/BENEFITS/Applying.asp" >Apply for Benefits</a></li> <li><a href="https://www.va.gov/health-care/how-to-apply/" >Apply for Health Care</a></li> <li><a href="https://www.myhealth.va.gov/pharmacy">Prescriptions</a></li> <li><a href="https://www.myhealth.va.gov/" >My Health<span>e</span>Vet</a></li> <li><a href="https://benefits.va.gov/insurance/choose.asp" >Life Insurance Online Applications</a></li> <li><a href="https://www.va.gov/vaforms/" >VA Forms</a></li> <li><a href="https://www.va.gov/landing2_locations.htm" >State and Local Resources</a></li> <li><a href="https://www.va.gov/op3/docs/StrategicPlanning/VA2014-2020strategicPlan.pdf" >Strat Plan FY 2014-2020</a> </li> <li><a href="https://www.va.gov/performance/index.asp" >VA Plans, Budget, & Performance</a></li> <li><a href="https://www.va.gov/ogc/accreditation.asp" >VA Claims Representation</a></li> </ul> </div> </div>  <div class="col"> <span class="blue-hdr top-level"><a href="javascript:void(0)">RESOURCES</a></span> <div class="ftrcls"> <ul> <li><a href="https://www.va.gov/jobs/">Careers at VA</a></li> <li><a href="https://www.vets.gov/employment/">Employment Center</a></li> <li><a href="https://www.oefoif.va.gov/" >Returning Service Members</a></li> <li><a href="https://www.benefits.va.gov/vocrehab/index.asp" >Vocational Rehabilitation & Employment</a></li> <li><a href="https://www.va.gov/homeless/" >Homeless Veterans</a></li> <li><a href="https://www.va.gov/womenvet/" >Women Veterans</a></li> <li><a href="https://www.va.gov/centerforminorityveterans/" >Minority Veterans</a></li> <li><a href="https://www.va.gov/opa/Plain_Language.asp" >Plain Language</a></li> <li><a href="https://www.va.gov/survivors/" >Surviving Spouses & Dependents</a></li> <li><a href="https://www.va.gov/adaptivesports/" >Adaptive Sports Program</a></li> </ul> </div> </div>  <div class="col"> <span class="blue-hdr top-level"><a href="javascript:void(0)">ADMINISTRATION</a></span> <div class="ftrcls"> <ul> <li><a href="https://www.va.gov/health/default.asp" >Veterans Health Administration</a></li> <li><a href="https://www.benefits.va.gov/benefits/" >Veterans Benefits Administration</a></li> <li><a href="https://www.cem.va.gov/" >National Cemetery Administration</a></li> </ul> </div> </div>  </div> </div> </div> <div id="sub-footer"> <p>U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420</p> <p class="small-print">Last updated November 29, 2023</p> </div> </div> </div> <div id="modal-crisisline" class="va-overlay va-modal va-modal-large" role="alertdialog" > <div class="va-crisis-panel va-modal-inner va-rounded--all"> <h2 id="va-crisis-title" class="va-text-center va-uppercase">Get help from Veterans Crisis Line</h2> <div class="va-overlay-body va-crisis-panel-body"> <ul> <li><a href="tel:988" tabindex='0' id="va-crisis-primary"><i class="fas fa-phone icon-left" aria-hidden="true"></i> Call <strong>988 (Press 1)</strong></a></li> <li><a href="sms:838255"><i class="fas fa-mobile-alt icon-left" aria-hidden="true"></i> Text to <b>838255</b></a></li> <li><a href="https://www.veteranscrisisline.net/ChatTermsOfService.aspx?account=Veterans%20Chat"><i class="far fa-comments"></i> Chat <b>confidentially now</b></a></li> <li ><i class="fa fa-fw fa-deaf icon-left margin-right-2 margin-top-2 fa-lg" aria-hidden="true"></i><a href="tel:18007994889"> Call TTY if you have hearing loss <strong>1-800-799-4889</strong></a></li> </ul> <p>If you are in crisis or having thoughts of suicide, visit <a href="https://www.veteranscrisisline.net/">VeteransCrisisLine.net</a> for more resources.</p> </div> <button class="va-modal-close va-overlay-close" type="button" id="va-vcl-close-btn"><span class="usa-sr-only">Close this modal</span> <i class="far fa-times-circle fa-2x va-overlay-close usa-text-blue" aria-hidden="true" title="close this modal"></i> </button> </div> </div> <script src="/va_files/2014/responsive/scripts/crisis-modal2.js"></script> <script> healthslider(); </script> </body> </html>

CINXE.COM

VHA National Center for Patient Safety Home