The Joint Patient Safety Reporting application, a collaborative Defense Health Agency and Veterans Health Administration effort, standardizes the process for medical teams to identify and document medical and dental errors, near-miss events, and close calls that may occur.

The application is partially funded by the Joint Incentive Fund, a program created by Congress to encourage development of knowledge sharing initiatives that benefit both the Department of Veterans Affairs and the Department of Defense. The JPSR system is an important part of an ongoing effort to achieve high-reliability organizational processes supporting quality clinical care and zero-preventable harm across all military hospitals and clinics.

JPSR is a globally deployed, web-based database and reporting system, explained Brian Anderson, health information technology systems lead for DHA Patient Safety Systems Workstream and functional JPSR manager. “It allows anyone in the VHA and DHA with a Common Access Card or a Personal Identity Verification card to identify patient safety issues and concerns, report discrete events, and investigate expediently for organizational learning.”

“The goal is to use this data to drive continuous improvement of clinical processes and decision support to provide the safest possible quality of care and reduce harm events toward zero-preventable harm levels.”

“The kinds of issues or events could be wide-ranging, from unsafe conditions; to near-misses; no harm; mild, moderate, or severe harm; and death,” said Anderson. “The database allows for anonymous or identified submitter reporting. It’s a continuous process improvement tool that makes it possible for us to improve our processes, strengthen our clinical delivery, and have safer, higher-quality care.”

According to Anderson, key features of the JPSR system are:

• Confidential, user-based access via the internet to protect data entry
• Risk event evaluation, root cause analysis, and determining if higher-level investigation is required
• Customizable analytical tools and reports to develop and implement proper quality control measures
• Dashboards for at-a-glance monitoring, measuring, and analyzing key data

The benefits of the JPSR system include consistent reporting across the federal health care enterprise, improved data analysis and reporting, and generating cost efficiencies by sharing software licenses and data centers while reducing system maintenance, helpdesk, and training workload costs.

Anderson commented that the JPSR is part of an effort to develop a culture of patient safety reporting and transparency across both agencies.

Improving Quality and Safety

“It's not just a medical or a dental error reporting database—it’s much broader than that,” said Anderson. “We want to stress it's a tool for continuous process improvement for quality and safety across the DOD and VHA, including U.S. Transportation Command’s Patient Movement division, commonly recognized as the world leader in global reach and aeromedical evacuation.”

Heidi King, chief of the DOD’s Patient Safety Program within the DHA, said JPSR plays an important role in creating a ‘ready, reliable care’ model by putting in place, “practices and approaches for making people aware it's okay to speak up.”

“If you don't have a culture of reporting and a culture of safety with a strong drive to get to zero harm, built on trust and transparency, where people feel psychologically safe to speak up—then, you will not have people report into the system,” said King.

She encourages patients to feel empowered to have a voice if there’s an issue.

“There needs to be willingness to admit something happened or identify those unsafe conditions,” she continued. “There must be an environment where people feel comfortable speaking up, they're respected for speaking up, and they talk about what happened in a respectful communication manner. It’s everybody's responsibility to speak up. Anytime, anywhere—always. This is what we do.”

King said the commitment of leadership to a culture focused on learning for improvement while treating everybody fairly and justly is vital.

“It needs to be made very clear to everyone in the organization what behaviors are acceptable and what behaviors are not acceptable, so people are willing to speak up,” she said. “Staff should know how the organization will respond to errors and that the response will be a fair approach. There is accountability for your own actions, but you are not blamed for faults in the system.”

Data Collection

Another important aspect of the system is the ability to collect valuable information useful for making systemic change, said King.

“The information we get when an organization has a strong culture of reporting enables us to learn from those events,” said King. “This is especially important because what happens in one location could happen in another.”

Anderson said this data serves as the basis for the journey of a high-reliability organization.

“We are able to leverage the information collected for organizational improvement by graphically analyzing the data, looking at trends, and learning from detailed descriptions of situations and events frontline staff encounter as they deliver patient care.”

“This is where organizational learning is so rich,” he continued. “You’re getting data directly from the frontline staff who are touching the patient. It's important that we get their perspective. If a particular tool or part of the electronic health record isn't working well for them, or they're having a hard time adopting to the workflow, we need to make an adjustment.”

Future of JPSR

Leadership is enthusiastic about both the JPSR modernization and the ongoing teamwork between the agencies.

“I am excited about the collaborative opportunities the Joint Incentive Fund programs afford the DHA and the VHA,” said U.S. Army Col. Marcus Moss, solution delivery division chief for the DOD.

“Using the common framework of Joint Patient Safety Reporting, both agencies can report incidents and near-misses, while utilizing a standardized methodology for data input, incident investigation, and root cause analysis. This holistic approach supports the DOD and the VA’s ability to exchange data and explore trends.”