San Diego Center for Patient Safety
Established by VA, UCSD Physicians

In an effort to improve patient safety and reduce the occurrence and severity of medical errors through research and education, the San Diego Center for Patient Safety (SDCPS) has been established as a collaborative effort between the Veterans Affairs (VA) San Diego Healthcare System and UCSD Health Sciences.

Funded by a $590,000 three-year grant by the Agency for Healthcare Research and Quality (AHRQ), the SDCPS is directed by Matthew B. Weinger, M.D., Director of the Anesthesia Ergonomics Research Laboratory at the VASDHS, and UCSD School of Medicine Professor of Anesthesiology. 

“This grant will not only provide funding for our initial patient safety research efforts, but will allow the SDCPS to grow to be come an essential community resource for healthcare providers and patients,” said  Weinger. 

The SDCPS will identify critical patient safety issues, conduct research to reduce the occurrence and severity of medical errors, and educate healthcare providers and patients throughout the San Diego community about patient safety. The Center will seek the participation of a broad range of academicians, physicians, scientists, community agencies and health systems, and patients.

The primary objectives and activities of the SDCPS are:

·             To build and educate a multidisciplinary collaborative research team to study critical issues in patient safety in a variety of health care settings, from operating rooms to nursing homes.

·             To utilize the Standardized Encounter technique as a research tool to identify critical patient safety issues, develop safety improvements to prevent errors. Standardized Encounters are simulated physician-patient scenarios, for example, utilizing professional actors who simulate the behavior and symptoms of patients, in person and in telephone communications.  SDCPS Co-Director Theodore Ganiats, M.D., Professor of Family and Preventive Medicine, said researchers will evaluate standard clinical routines using Standardized Encounters to investigate the cause of events that can lead to patient injury.

·             To develop Patient Safety Laboratories for both real and simulated training and research in a range of clinical care environments.  The team plans to create a Realistic Patient Simulation environment that recreates the complexity of the operating room, intensive care unit or emergency room, using a sophisticated computer-controlled mannequin that mimics patient responses to medical treatment, from blood pressure and heart rate to reaction to pain.

·             To develop a website, training programs, and patient safety course materials to assist clinicians and patients to learn about and implement new safety techniques.

SDCPS’ activities will promote the concept that clinical care providers can and should create safety. This is in contrast to the view that safety issues arise because clinicians make errors, Weinger said.

“Most medical errors are a result of system or device failures in which multiple events that compound to create a dangerous situation,” he said. “We often fail to appreciate how many medical errors are avoided because experienced clinicians identify a potentially hazardous situation and figure out ways to avoid or reduce the consequences to the patient. We need to understand the conditions that distinguish safe and unsafe medical care.”

A safety factor of particular interest to SDCPS investigators is the role of communication – between the clinician and patient, and between clinicians – in diagnosis and treatment.  Previous studies have shown that communication failure is a contributor to medical errors, and in a diverse community like San Diego, with language and cultural influences coming into play, the risk of error and injury increases, said Weinger.

SDCPS is part of a wider effort by both the VA San Diego Healthcare System and UCSD Health Sciences to improve patient safety. Weinger recently received more than $1 million in new grant support from the Veterans Health Administration (VHA) Health Services Research and Development (HSR&D) Service and the Agency for Healthcare Research and Quality (AHRQ) to study unexpected clinical events during anesthesia and surgery.  The VHA and AHRQ have taken the lead in nationwide patient safety efforts.

In addition to this research, the VA San Diego Healthcare System and UCSD Healthcare have implemented numerous patient safety initiatives including sentinel event analysis, bar coding for medication administration, computerized medication ordering, and automated pharmacy medication filling systems.