Article

Background

Parotid gland malignancies are a rare subset of salivary gland tumors, comprising approximately 1–3% of all head and neck cancers. While distant metastases commonly involve the lungs, brain metastases are exceedingly rare and remain poorly characterized. Management typically includes stereotactic radiosurgery or whole-brain radiation. This study evaluates the incidence, clinicopathologic features, and survival outcomes of patients with parotid gland tumors and brain metastases using data from Surveillance, Epidemiology, and End Results (SEER) database.

Methods

SEER database (2010–2022) was queried for patients diagnosed with primary malignant neoplasms of the parotid gland (ICD-O-3 site code C07.9). Cases of brain metastases were identified using SEER metastatic site variables. Age-adjusted incidence rates (IR) per 100,000 population were calculated using SEER*Stat 8.4.5. Kaplan-Meier survival analyses were conducted using GraphPad Prism, and survival differences were assessed using the log-rank test.

Results

Among 12,951 patients diagnosed with parotid malignancy, 47 (0.36%) had brain metastases. The median age at diagnosis was 67 years, and 77.5% were male. The overall incidence rate (IR) of brain metastases was 0.00235 per 100,000 population, with a significantly higher rate observed in males compared to females (p < 0.0001). The most common histologic subtype associated with brain involvement was squamous cell carcinoma (SCC, n=10), followed by adenocarcinoma. Median overall survival (mOS) for patients with brain metastases was 2 months (hazard ratio [HR] 6.28; 95% CI: 2.71–14.55), compared to 131 months for those without brain involvement (p < 0.001). 1-year cancer-specific survival for patients with brain metastases was 38%. Among patients with parotid SCC and brain metastases, mOS was 3 months, compared to 39 months in those without brain involvement (HR 5.70; 95% CI: 1.09–29.68; p < 0.0001).

Conclusions

Brain metastases from parotid gland cancers, though rare, are associated with markedly poor outcomes. This highlights the importance of early neurologic assessment and brain imaging in high-risk patients, particularly with SCC histology. Prior studies have shown that TP53 mutations are common in parotid SCC, but their role in CNS spread remains unclear. Future research should explore molecular pathways underlying neurotropism in parotid cancers and investigate targeted systemic therapies with CNS penetration to improve outcomes.

Background

Parotid gland malignancies are a rare subset of salivary gland tumors, comprising approximately 1–3% of all head and neck cancers. While distant metastases commonly involve the lungs, brain metastases are exceedingly rare and remain poorly characterized. Management typically includes stereotactic radiosurgery or whole-brain radiation. This study evaluates the incidence, clinicopathologic features, and survival outcomes of patients with parotid gland tumors and brain metastases using data from Surveillance, Epidemiology, and End Results (SEER) database.

Methods

SEER database (2010–2022) was queried for patients diagnosed with primary malignant neoplasms of the parotid gland (ICD-O-3 site code C07.9). Cases of brain metastases were identified using SEER metastatic site variables. Age-adjusted incidence rates (IR) per 100,000 population were calculated using SEER*Stat 8.4.5. Kaplan-Meier survival analyses were conducted using GraphPad Prism, and survival differences were assessed using the log-rank test.

Results

Among 12,951 patients diagnosed with parotid malignancy, 47 (0.36%) had brain metastases. The median age at diagnosis was 67 years, and 77.5% were male. The overall incidence rate (IR) of brain metastases was 0.00235 per 100,000 population, with a significantly higher rate observed in males compared to females (p < 0.0001). The most common histologic subtype associated with brain involvement was squamous cell carcinoma (SCC, n=10), followed by adenocarcinoma. Median overall survival (mOS) for patients with brain metastases was 2 months (hazard ratio [HR] 6.28; 95% CI: 2.71–14.55), compared to 131 months for those without brain involvement (p < 0.001). 1-year cancer-specific survival for patients with brain metastases was 38%. Among patients with parotid SCC and brain metastases, mOS was 3 months, compared to 39 months in those without brain involvement (HR 5.70; 95% CI: 1.09–29.68; p < 0.0001).

Conclusions

Brain metastases from parotid gland cancers, though rare, are associated with markedly poor outcomes. This highlights the importance of early neurologic assessment and brain imaging in high-risk patients, particularly with SCC histology. Prior studies have shown that TP53 mutations are common in parotid SCC, but their role in CNS spread remains unclear. Future research should explore molecular pathways underlying neurotropism in parotid cancers and investigate targeted systemic therapies with CNS penetration to improve outcomes.

Background

Parotid gland malignancies are a rare subset of salivary gland tumors, comprising approximately 1–3% of all head and neck cancers. While distant metastases commonly involve the lungs, brain metastases are exceedingly rare and remain poorly characterized. Management typically includes stereotactic radiosurgery or whole-brain radiation. This study evaluates the incidence, clinicopathologic features, and survival outcomes of patients with parotid gland tumors and brain metastases using data from Surveillance, Epidemiology, and End Results (SEER) database.

Methods

SEER database (2010–2022) was queried for patients diagnosed with primary malignant neoplasms of the parotid gland (ICD-O-3 site code C07.9). Cases of brain metastases were identified using SEER metastatic site variables. Age-adjusted incidence rates (IR) per 100,000 population were calculated using SEER*Stat 8.4.5. Kaplan-Meier survival analyses were conducted using GraphPad Prism, and survival differences were assessed using the log-rank test.

Results

Among 12,951 patients diagnosed with parotid malignancy, 47 (0.36%) had brain metastases. The median age at diagnosis was 67 years, and 77.5% were male. The overall incidence rate (IR) of brain metastases was 0.00235 per 100,000 population, with a significantly higher rate observed in males compared to females (p < 0.0001). The most common histologic subtype associated with brain involvement was squamous cell carcinoma (SCC, n=10), followed by adenocarcinoma. Median overall survival (mOS) for patients with brain metastases was 2 months (hazard ratio [HR] 6.28; 95% CI: 2.71–14.55), compared to 131 months for those without brain involvement (p < 0.001). 1-year cancer-specific survival for patients with brain metastases was 38%. Among patients with parotid SCC and brain metastases, mOS was 3 months, compared to 39 months in those without brain involvement (HR 5.70; 95% CI: 1.09–29.68; p < 0.0001).

Conclusions

Brain metastases from parotid gland cancers, though rare, are associated with markedly poor outcomes. This highlights the importance of early neurologic assessment and brain imaging in high-risk patients, particularly with SCC histology. Prior studies have shown that TP53 mutations are common in parotid SCC, but their role in CNS spread remains unclear. Future research should explore molecular pathways underlying neurotropism in parotid cancers and investigate targeted systemic therapies with CNS penetration to improve outcomes.

Background

Papillary cystadenocarcinoma is a rare, aggressive malignancy typically arising in the ovaries, often following malignant transformation of benign precursors. Characterized by local invasion and recurrence, it lacks standardized treatment protocols and comprehensive epidemiological data. Existing literature is limited to case reports and small series, leaving gaps in population-level data to guide clinical decision-making. This study uses the National Cancer Database (NCDB) to assess demographic, socioeconomic, and treatment patterns to identify disparities and inform management.

Methods

A retrospective cohort analysis of 345 patients with histologically confirmed papillary cystadenocarcinoma (ICD-O-3 code 8450) was conducted using the 2004–2020 NCDB. Demographic, treatment, and survival data were described; incidence trends were assessed via linear regression; and survival was analyzed using Kaplan-Meier curves.

Results

The cohort was predominantly female (97.1%), mean age 62.1 years (SD = 14.0), and 87.2% White. Most had private insurance (44.9%) or Medicare (40.9%). Over half (51.9%) resided in metropolitan areas >1 million. Primary tumor sites were ovarian (80.0%) and endometrial (5.2%), with 39.7% presenting at Stage III. Surgery was performed in 90.4% of cases, with 51.9% achieving negative margins. Most were treated at comprehensive community (41.0%) or academic/research programs (28.7%). Primary therapies included chemotherapy (62.3%), radiation (6.4%), and hormone therapy (1.7%). Thirty-day mortality was 1.9%, and 90-day mortality was 5.4%. Survival was 97.7% at 2 years, 94.2% at 5 years, and 88.6% at 10 years. Mean survival was 97.5 months (95% CI: 88.2–106.7).

Conclusions

This is the first NCDB-based analysis of papillary cystadenocarcinoma, offering insight into its clinical characteristics. Ovarian and endometrial origins were most common, reinforcing its gynecologic profile. High surgical rates and margin negativity suggest aggressive local treatment is central to management. Disparities emerged: patients were more likely to live in urban areas, hold private insurance, and receive care at community programs. These findings highlight the need for further investigation into socioeconomic inequities and may inform future guidelines to improve equitable care delivery across health systems, including community-based programs such as the VHA.

Background

Papillary cystadenocarcinoma is a rare, aggressive malignancy typically arising in the ovaries, often following malignant transformation of benign precursors. Characterized by local invasion and recurrence, it lacks standardized treatment protocols and comprehensive epidemiological data. Existing literature is limited to case reports and small series, leaving gaps in population-level data to guide clinical decision-making. This study uses the National Cancer Database (NCDB) to assess demographic, socioeconomic, and treatment patterns to identify disparities and inform management.

Methods

A retrospective cohort analysis of 345 patients with histologically confirmed papillary cystadenocarcinoma (ICD-O-3 code 8450) was conducted using the 2004–2020 NCDB. Demographic, treatment, and survival data were described; incidence trends were assessed via linear regression; and survival was analyzed using Kaplan-Meier curves.

Results

The cohort was predominantly female (97.1%), mean age 62.1 years (SD = 14.0), and 87.2% White. Most had private insurance (44.9%) or Medicare (40.9%). Over half (51.9%) resided in metropolitan areas >1 million. Primary tumor sites were ovarian (80.0%) and endometrial (5.2%), with 39.7% presenting at Stage III. Surgery was performed in 90.4% of cases, with 51.9% achieving negative margins. Most were treated at comprehensive community (41.0%) or academic/research programs (28.7%). Primary therapies included chemotherapy (62.3%), radiation (6.4%), and hormone therapy (1.7%). Thirty-day mortality was 1.9%, and 90-day mortality was 5.4%. Survival was 97.7% at 2 years, 94.2% at 5 years, and 88.6% at 10 years. Mean survival was 97.5 months (95% CI: 88.2–106.7).

Conclusions

This is the first NCDB-based analysis of papillary cystadenocarcinoma, offering insight into its clinical characteristics. Ovarian and endometrial origins were most common, reinforcing its gynecologic profile. High surgical rates and margin negativity suggest aggressive local treatment is central to management. Disparities emerged: patients were more likely to live in urban areas, hold private insurance, and receive care at community programs. These findings highlight the need for further investigation into socioeconomic inequities and may inform future guidelines to improve equitable care delivery across health systems, including community-based programs such as the VHA.

Background

Papillary cystadenocarcinoma is a rare, aggressive malignancy typically arising in the ovaries, often following malignant transformation of benign precursors. Characterized by local invasion and recurrence, it lacks standardized treatment protocols and comprehensive epidemiological data. Existing literature is limited to case reports and small series, leaving gaps in population-level data to guide clinical decision-making. This study uses the National Cancer Database (NCDB) to assess demographic, socioeconomic, and treatment patterns to identify disparities and inform management.

Methods

A retrospective cohort analysis of 345 patients with histologically confirmed papillary cystadenocarcinoma (ICD-O-3 code 8450) was conducted using the 2004–2020 NCDB. Demographic, treatment, and survival data were described; incidence trends were assessed via linear regression; and survival was analyzed using Kaplan-Meier curves.

Results

The cohort was predominantly female (97.1%), mean age 62.1 years (SD = 14.0), and 87.2% White. Most had private insurance (44.9%) or Medicare (40.9%). Over half (51.9%) resided in metropolitan areas >1 million. Primary tumor sites were ovarian (80.0%) and endometrial (5.2%), with 39.7% presenting at Stage III. Surgery was performed in 90.4% of cases, with 51.9% achieving negative margins. Most were treated at comprehensive community (41.0%) or academic/research programs (28.7%). Primary therapies included chemotherapy (62.3%), radiation (6.4%), and hormone therapy (1.7%). Thirty-day mortality was 1.9%, and 90-day mortality was 5.4%. Survival was 97.7% at 2 years, 94.2% at 5 years, and 88.6% at 10 years. Mean survival was 97.5 months (95% CI: 88.2–106.7).

Conclusions

This is the first NCDB-based analysis of papillary cystadenocarcinoma, offering insight into its clinical characteristics. Ovarian and endometrial origins were most common, reinforcing its gynecologic profile. High surgical rates and margin negativity suggest aggressive local treatment is central to management. Disparities emerged: patients were more likely to live in urban areas, hold private insurance, and receive care at community programs. These findings highlight the need for further investigation into socioeconomic inequities and may inform future guidelines to improve equitable care delivery across health systems, including community-based programs such as the VHA.

Background

19.8% of all deaths in the US in 2023 were due to cancer. Despite its prevalence, there is minimal literature analyzing geographical trends in end-of-life care in cancer patients. This study aims to assess the evolution of end-of-life preferences in cancer patients, particularly during the COVID-19 pandemic, and account for geographical disparities to optimize palliative care delivery.

Methods

The CDC WONDER database was used to collect data on place of death (home, hospice, medical facilities, nursing homes) in patients over 25 years old that died with malignant neoplasms (ICD 10: C00- C97) in the US from 2003-2023. Deaths were stratified by region and urbanization. Proportional mortality was calculated, and statistically significant trends in mortality over time were identified using Joinpoint regression.

Results

There were 13,654,631 total deaths from malignant neoplasms over the study period. Home (40.3%) was the most common place of death followed by medical facilities (30.4%), nursing homes (14.3%), and hospice (8.9%). In 2020, all places experienced a decreased in proportion except for home which rose 7.0% from 41.7% to 48.7%. The South had the highest hospice rates (11.3%); 5.0% greater than the next highest region (Northeast; 8.3%). The West had the highest home rates (47.1%); 6.2% greater than the next closest region (South; 40.9%). The Northeast had the highest medical facility rates (36.0%); 5.5% higher than the next highest region (South, 30.5%). Nonmetro areas (< 50,000 population) had the lowest hospice (4.9%) and highest nursing home rates (15.8%). They also saw a substantial jump (+15.4%) in home deaths from 2019-21. All urbanizations saw a drop in medical facility deaths in 2020 but all have since climbed to surpass their 2019 rates except for nonmetro areas which have dropped 7.3% from 2020-2023.

Conclusion

Hospice and home deaths have increased in frequency with home deaths spiking during the COVID-19 pandemic. Geographical disparities persist in end-of-life care, particularly in nonmetro areas. This highlights the need to increase education and access to palliative care. Further research should aim at why the rural populations have failed to revert to pre-COVID trends like the other urbanization groups.

Background

19.8% of all deaths in the US in 2023 were due to cancer. Despite its prevalence, there is minimal literature analyzing geographical trends in end-of-life care in cancer patients. This study aims to assess the evolution of end-of-life preferences in cancer patients, particularly during the COVID-19 pandemic, and account for geographical disparities to optimize palliative care delivery.

Methods

The CDC WONDER database was used to collect data on place of death (home, hospice, medical facilities, nursing homes) in patients over 25 years old that died with malignant neoplasms (ICD 10: C00- C97) in the US from 2003-2023. Deaths were stratified by region and urbanization. Proportional mortality was calculated, and statistically significant trends in mortality over time were identified using Joinpoint regression.

Results

There were 13,654,631 total deaths from malignant neoplasms over the study period. Home (40.3%) was the most common place of death followed by medical facilities (30.4%), nursing homes (14.3%), and hospice (8.9%). In 2020, all places experienced a decreased in proportion except for home which rose 7.0% from 41.7% to 48.7%. The South had the highest hospice rates (11.3%); 5.0% greater than the next highest region (Northeast; 8.3%). The West had the highest home rates (47.1%); 6.2% greater than the next closest region (South; 40.9%). The Northeast had the highest medical facility rates (36.0%); 5.5% higher than the next highest region (South, 30.5%). Nonmetro areas (< 50,000 population) had the lowest hospice (4.9%) and highest nursing home rates (15.8%). They also saw a substantial jump (+15.4%) in home deaths from 2019-21. All urbanizations saw a drop in medical facility deaths in 2020 but all have since climbed to surpass their 2019 rates except for nonmetro areas which have dropped 7.3% from 2020-2023.

Conclusion

Hospice and home deaths have increased in frequency with home deaths spiking during the COVID-19 pandemic. Geographical disparities persist in end-of-life care, particularly in nonmetro areas. This highlights the need to increase education and access to palliative care. Further research should aim at why the rural populations have failed to revert to pre-COVID trends like the other urbanization groups.

Background

19.8% of all deaths in the US in 2023 were due to cancer. Despite its prevalence, there is minimal literature analyzing geographical trends in end-of-life care in cancer patients. This study aims to assess the evolution of end-of-life preferences in cancer patients, particularly during the COVID-19 pandemic, and account for geographical disparities to optimize palliative care delivery.

Methods

The CDC WONDER database was used to collect data on place of death (home, hospice, medical facilities, nursing homes) in patients over 25 years old that died with malignant neoplasms (ICD 10: C00- C97) in the US from 2003-2023. Deaths were stratified by region and urbanization. Proportional mortality was calculated, and statistically significant trends in mortality over time were identified using Joinpoint regression.

Results

There were 13,654,631 total deaths from malignant neoplasms over the study period. Home (40.3%) was the most common place of death followed by medical facilities (30.4%), nursing homes (14.3%), and hospice (8.9%). In 2020, all places experienced a decreased in proportion except for home which rose 7.0% from 41.7% to 48.7%. The South had the highest hospice rates (11.3%); 5.0% greater than the next highest region (Northeast; 8.3%). The West had the highest home rates (47.1%); 6.2% greater than the next closest region (South; 40.9%). The Northeast had the highest medical facility rates (36.0%); 5.5% higher than the next highest region (South, 30.5%). Nonmetro areas (< 50,000 population) had the lowest hospice (4.9%) and highest nursing home rates (15.8%). They also saw a substantial jump (+15.4%) in home deaths from 2019-21. All urbanizations saw a drop in medical facility deaths in 2020 but all have since climbed to surpass their 2019 rates except for nonmetro areas which have dropped 7.3% from 2020-2023.

Conclusion

Hospice and home deaths have increased in frequency with home deaths spiking during the COVID-19 pandemic. Geographical disparities persist in end-of-life care, particularly in nonmetro areas. This highlights the need to increase education and access to palliative care. Further research should aim at why the rural populations have failed to revert to pre-COVID trends like the other urbanization groups.

Background

In 2024, it was estimated that 2,001,140 new cases of cancer were diagnosed in the United States with 611,720 people succumbing to the disease. There is scant literature analyzing how the place of death in cancer patients has evolved over time, particularly during the COVID-19 pandemic, and how it varies demographically. This study aims to analyze the evolution of end-of-life preferences in cancer patients and assess for racial or sexual disparities to optimize palliative care and ensure it aligns with the patient’s wishes.

Methods

The CDC Wonder database was used to collect data on place of death (home, hospice, medical facilities, nursing homes) in patients over 25 years old who died with malignant neoplasms (ICD-10: C00-C97) in the US from 2003-2023. Deaths were stratified by sex and race. Proportional mortality was calculated, and statistically significant temporal trends in mortality were identified using Joinpoint regression.

Results

From 2003 to 2023, there were 13,654,631 total deaths from malignant cancer. Home deaths were the most common (40.3%) followed by medical facilities (30.4%), nursing homes (14.3%), and hospice (8.9%). In 2020, all places experienced a decrease in proportion except for home which rose 7.1%. From 2003-2023, home (+4.0%) and hospice (+10.0%) rose in frequency while medical facility (-10.9%) and nursing home (-6.8%) declined. Females died in nursing homes at a greater proportion than males (15.8% vs. 13.1%) while males died in medical facilities more frequently (32.4% vs. 28.8%). Black patients were the least likely to die at home (33.1%), 5.9% less than the next lowest (Asian/ Pacific Islander; 39.0%), while Hispanic patients were most likely (46.9%); 5.7% more than the next highest (White, 41.7%). White patients were the least likely to die in medical facilities (28.4%) but were also most likely to die in nursing homes (15.3%).

Conclusions

Hospice and home deaths have increased in frequency with home deaths spiking during the COVID-19 pandemic. Disparities persist in end-of-life care across both sex and racial groups. This highlights the need to increase education and access to palliative care. Further research should elucidate cultural and racial discrepancies surrounding end-of-life treatment and preferences to provide context for these differences.

Background

In 2024, it was estimated that 2,001,140 new cases of cancer were diagnosed in the United States with 611,720 people succumbing to the disease. There is scant literature analyzing how the place of death in cancer patients has evolved over time, particularly during the COVID-19 pandemic, and how it varies demographically. This study aims to analyze the evolution of end-of-life preferences in cancer patients and assess for racial or sexual disparities to optimize palliative care and ensure it aligns with the patient’s wishes.

Methods

The CDC Wonder database was used to collect data on place of death (home, hospice, medical facilities, nursing homes) in patients over 25 years old who died with malignant neoplasms (ICD-10: C00-C97) in the US from 2003-2023. Deaths were stratified by sex and race. Proportional mortality was calculated, and statistically significant temporal trends in mortality were identified using Joinpoint regression.

Results

From 2003 to 2023, there were 13,654,631 total deaths from malignant cancer. Home deaths were the most common (40.3%) followed by medical facilities (30.4%), nursing homes (14.3%), and hospice (8.9%). In 2020, all places experienced a decrease in proportion except for home which rose 7.1%. From 2003-2023, home (+4.0%) and hospice (+10.0%) rose in frequency while medical facility (-10.9%) and nursing home (-6.8%) declined. Females died in nursing homes at a greater proportion than males (15.8% vs. 13.1%) while males died in medical facilities more frequently (32.4% vs. 28.8%). Black patients were the least likely to die at home (33.1%), 5.9% less than the next lowest (Asian/ Pacific Islander; 39.0%), while Hispanic patients were most likely (46.9%); 5.7% more than the next highest (White, 41.7%). White patients were the least likely to die in medical facilities (28.4%) but were also most likely to die in nursing homes (15.3%).

Conclusions

Hospice and home deaths have increased in frequency with home deaths spiking during the COVID-19 pandemic. Disparities persist in end-of-life care across both sex and racial groups. This highlights the need to increase education and access to palliative care. Further research should elucidate cultural and racial discrepancies surrounding end-of-life treatment and preferences to provide context for these differences.

Background

In 2024, it was estimated that 2,001,140 new cases of cancer were diagnosed in the United States with 611,720 people succumbing to the disease. There is scant literature analyzing how the place of death in cancer patients has evolved over time, particularly during the COVID-19 pandemic, and how it varies demographically. This study aims to analyze the evolution of end-of-life preferences in cancer patients and assess for racial or sexual disparities to optimize palliative care and ensure it aligns with the patient’s wishes.

Methods

The CDC Wonder database was used to collect data on place of death (home, hospice, medical facilities, nursing homes) in patients over 25 years old who died with malignant neoplasms (ICD-10: C00-C97) in the US from 2003-2023. Deaths were stratified by sex and race. Proportional mortality was calculated, and statistically significant temporal trends in mortality were identified using Joinpoint regression.

Results

From 2003 to 2023, there were 13,654,631 total deaths from malignant cancer. Home deaths were the most common (40.3%) followed by medical facilities (30.4%), nursing homes (14.3%), and hospice (8.9%). In 2020, all places experienced a decrease in proportion except for home which rose 7.1%. From 2003-2023, home (+4.0%) and hospice (+10.0%) rose in frequency while medical facility (-10.9%) and nursing home (-6.8%) declined. Females died in nursing homes at a greater proportion than males (15.8% vs. 13.1%) while males died in medical facilities more frequently (32.4% vs. 28.8%). Black patients were the least likely to die at home (33.1%), 5.9% less than the next lowest (Asian/ Pacific Islander; 39.0%), while Hispanic patients were most likely (46.9%); 5.7% more than the next highest (White, 41.7%). White patients were the least likely to die in medical facilities (28.4%) but were also most likely to die in nursing homes (15.3%).

Conclusions

Hospice and home deaths have increased in frequency with home deaths spiking during the COVID-19 pandemic. Disparities persist in end-of-life care across both sex and racial groups. This highlights the need to increase education and access to palliative care. Further research should elucidate cultural and racial discrepancies surrounding end-of-life treatment and preferences to provide context for these differences.

Background

With the onset of precision oncology, findings from germline mutational analysis have been helpful in treating patients with cancer and aids in cancer prevention, early detection, and improved overall outcomes. Germline genetic testing is now part of the standard of care for certain types of patients with prostate cancer. There is a very limited body of work that investigated demographic, disease- related and social factors that may be influencing Veterans’ participation in germline genetic testing. This study helps to identify whether certain factors may be influencing decisions on participation in prostate germline testing among Veterans with prostate malignancy.

Methods

The study was conducted using retrospective chart review. Data was collected from the periods of August 1, 2022 to December 31, 2023 among Veterans with prostate cancer who met criteria for germline genetic testing. Demographic and clinical information were collected including age, race, extent of disease (high risk, very high-risk or metastatic disease), significant co-morbidities, educational level, family and personal history of cancer, travel time, germline genetic test findings, impact on treatment approaches, referral for genetic counseling, and whether Veterans agreed or declined germline genetic testing. Data was analyzed using descriptive statistics. A total of 180 charts were reviewed, with 171 meeting the criteria for inclusion. The mean age of the participants is 73, with the youngest being 55 and the oldest being 101 years old. Majority of the participants were African American (77%).

Results

Only about two percent of those who met the inclusion criteria declined to undergo testing with the one living the farthest away from the testing hospital residing 18 miles away. Those who declined testing ranged in age from 67 to 88, majority had high risk prostate cancer and no family history of malignancy, and had 0-1 serious co-morbidity. None of their educational informational was available for review.

Conclusions

Participation in germline genetic testing can be enhanced with adequate patient education and availability of accessible resources, even among patient populations that are not always well-represented in clinical research. The presence of multiple serious co-morbidities and distance from a testing facility do not seem to contribute to hesitancy in germline genetic testing participation.

Background

With the onset of precision oncology, findings from germline mutational analysis have been helpful in treating patients with cancer and aids in cancer prevention, early detection, and improved overall outcomes. Germline genetic testing is now part of the standard of care for certain types of patients with prostate cancer. There is a very limited body of work that investigated demographic, disease- related and social factors that may be influencing Veterans’ participation in germline genetic testing. This study helps to identify whether certain factors may be influencing decisions on participation in prostate germline testing among Veterans with prostate malignancy.

Methods

The study was conducted using retrospective chart review. Data was collected from the periods of August 1, 2022 to December 31, 2023 among Veterans with prostate cancer who met criteria for germline genetic testing. Demographic and clinical information were collected including age, race, extent of disease (high risk, very high-risk or metastatic disease), significant co-morbidities, educational level, family and personal history of cancer, travel time, germline genetic test findings, impact on treatment approaches, referral for genetic counseling, and whether Veterans agreed or declined germline genetic testing. Data was analyzed using descriptive statistics. A total of 180 charts were reviewed, with 171 meeting the criteria for inclusion. The mean age of the participants is 73, with the youngest being 55 and the oldest being 101 years old. Majority of the participants were African American (77%).

Results

Only about two percent of those who met the inclusion criteria declined to undergo testing with the one living the farthest away from the testing hospital residing 18 miles away. Those who declined testing ranged in age from 67 to 88, majority had high risk prostate cancer and no family history of malignancy, and had 0-1 serious co-morbidity. None of their educational informational was available for review.

Conclusions

Participation in germline genetic testing can be enhanced with adequate patient education and availability of accessible resources, even among patient populations that are not always well-represented in clinical research. The presence of multiple serious co-morbidities and distance from a testing facility do not seem to contribute to hesitancy in germline genetic testing participation.

Background

With the onset of precision oncology, findings from germline mutational analysis have been helpful in treating patients with cancer and aids in cancer prevention, early detection, and improved overall outcomes. Germline genetic testing is now part of the standard of care for certain types of patients with prostate cancer. There is a very limited body of work that investigated demographic, disease- related and social factors that may be influencing Veterans’ participation in germline genetic testing. This study helps to identify whether certain factors may be influencing decisions on participation in prostate germline testing among Veterans with prostate malignancy.

Methods

The study was conducted using retrospective chart review. Data was collected from the periods of August 1, 2022 to December 31, 2023 among Veterans with prostate cancer who met criteria for germline genetic testing. Demographic and clinical information were collected including age, race, extent of disease (high risk, very high-risk or metastatic disease), significant co-morbidities, educational level, family and personal history of cancer, travel time, germline genetic test findings, impact on treatment approaches, referral for genetic counseling, and whether Veterans agreed or declined germline genetic testing. Data was analyzed using descriptive statistics. A total of 180 charts were reviewed, with 171 meeting the criteria for inclusion. The mean age of the participants is 73, with the youngest being 55 and the oldest being 101 years old. Majority of the participants were African American (77%).

Results

Only about two percent of those who met the inclusion criteria declined to undergo testing with the one living the farthest away from the testing hospital residing 18 miles away. Those who declined testing ranged in age from 67 to 88, majority had high risk prostate cancer and no family history of malignancy, and had 0-1 serious co-morbidity. None of their educational informational was available for review.

Conclusions

Participation in germline genetic testing can be enhanced with adequate patient education and availability of accessible resources, even among patient populations that are not always well-represented in clinical research. The presence of multiple serious co-morbidities and distance from a testing facility do not seem to contribute to hesitancy in germline genetic testing participation.

Rural veterans are prescribed long-term opioid therapy for chronic pain at higher rates than urban veterans, increasing their risk of developing opioid use disorder (OUD).^1,2 Veterans with co-occurring OUD and chronic pain have more severe health concerns, as well as higher rates of homelessness, psychoactive drug misuse, and mental health disorders, compared to veterans with either chronic pain or OUD alone.³ Interdisciplinary team (IDT) care is recommended for both chronic pain and OUD.^4,5 Rural veterans with co-occurring chronic pain and OUD, however, are often unable to access IDTs due to long travel and wait times. As a result, these rural veterans often receive care from primary care practitioners (PCPs) who lack training in pain management and addiction and have low confidence in their ability to provide optimal treatment.^6,7

In the Veterans Health Administration, electronic consultations (e-consults) provide support to PCPs by recommending evidence-based approaches such as buprenorphine for OUD and pain IDTs for chronic pain.^5,8 However, research on the use of e-consults to connect to IDT care for co-occurring chronic pain and OUD are lacking, as well as studies on IDTs using innovative methods (eg, shared appointments) to overcome treatment barriers (eg, multiple appointments) for rural veterans at higher risk for co-occurring OUD and chronic pain. 

This quality improvement study sought to determine the feasibility and impact of a pharmacy e-consult service that provided pain medication recommendations and subsequent referrals to RESTORE, a shared appointment program with an IDT, for assessment and treatment of chronic pain and OUD.

Methods

This retrospective chart review was approved as nonresearch by the Institutional Review Board Chair at the Salem Veterans Affairs Healthcare System (SVAHS), a low-complexity medical center in Virginia that primarily serves a rural and highly rural Central Appalachian veteran population.

This study included veterans whose clinicians placed a pain medication e-consult requesting recommendations for medication adjustments and/or a referral to RESTORE from January 1, 2022, through January 6, 2023. Requests for services that could not be provided through an e-consult were excluded (Figure 1). Veterans who had a pain medication e-consult were identified in the SVAHS electronic medical record (EMR). Data extracted from the EMR included demographics, referral source, reason for referral, RESTORE appointment attendance, OUD diagnosis made during the RESTORE initial evaluation, implementation of medication recommendations by the referrer within 6 months, engagement in ≥ 3 pain education classes, and a shared appointment with a pain IDT within 6 months. Data were entered into a REDCap database, and descriptive statistics summarized the results. Feasibility was assessed by use of the e-consult by PCPs, attendance at the RESTORE appointment, and OUD diagnosis by the RESTORE team.

RESTORE Intervention

A pain medication e-consult was followed by referral to a shared appointment with the RESTORE IDT, with subsequent referrals to a pain IDT for chronic pain management if the veteran was amenable.

Pain medication e-consults in the EMR prompted a chart review by a clinical pharmacist practitioner (CPP). Recommendations for changes to medication regimens were documented in the EMR. At completion of the e-consult, the referring clinician received an automated view alert.

Veterans (and a support person, if preferred) were seen in a 60-minute, face-to-face shared appointment which included a psychologist, CPP, and pain physician. The psychologist conducted an OUD diagnostic interview, provided diagnostic feedback, and used motivational interviewing to provide psychoeducation on the biopsychosocial model of chronic pain, the IDT approach to chronic pain, and an overview of pain IDT care locally available. A CPP and physician then described medication options available to address OUD, if applicable. Together, the IDT and patient used shared decision making to determine a comprehensive treatment plan that may include a referral to the SVAHS PREVAIL Center for Chronic Pain IDT track (PREVAIL IDT track), a referral to substance use care in the case of polysubstance use, or medication initiation.^9-11 If medication was prescribed, the patient was subsequently followed by the CPP through phone calls and face-to-face appointments at regularly scheduled intervals in coordination with the prescriber until they were stabilized. After stabilization, the prescription would be managed by their PCP (Figure 2). Veterans whose clinical condition changed significantly or worsened after returning to their PCP were invited to be reevaluated by the RESTORE team and restart care in that program. Individuals who were actively receiving RESTORE team care were discussed in a weekly care coordination meeting with all clinicians from both the PREVAIL and RESTORE teams.

Program Metrics

Pain medication e-consults were placed for 77 patients; 7 were excluded as inappropriate referral requests. Seventy (83%) e-consults were placed by PCPs (Table). Fifty-seven referring PCPs (81%) implemented ≥ 1 medication recommendation and 41 (59%) implemented all recommendations within 6 months. CPPs referred 19 individuals to RESTORE due to concerns related to high risk. All attended the initial evaluation appointment with the RESTORE team, 17 (89%) agreed to be referred to PREVAIL IDT track for nonpharmacologic pain care, and 9 (53%) engaged with that care within 6 months. Of those who attended RESTORE, 7 patients (37%) initiated buprenorphine for OUD with 6 (86%) being prescribed buprenorphine for ≥ 6 months.

Discussion

Most e-consults placed at SVAHS, which primarily serves a rural veteran population in Central Appalachia, resulted in veterans engaging in evidence-based treatment for co-occurring chronic pain and OUD. The use of e-consults and subsequent shared appointments with an IDT appears to be feasible, as the service was most often used by PCPs who often feel unequipped to manage chronic pain.⁷ The attendance rate for the RESTORE appointments was notable given the typically poor follow-up for patients with OUD. It supports the feasibility of a shared appointment approach which may overcome frequent barriers to care in this vulnerable population (ie, time, transportation). By attending 1 appointment with all clinicians present as opposed to multiple appointments, veterans experience fewer barriers than attending multiple appointments. RESTORE continues to be offered as an active clinical service whose implementation is now supported by changes to SVAHS policies. Since this study was conducted, the number of patients seen weekly has doubled and will soon be tripled based on high demand from PCPs.

While this study was limited to 1 site, had a small sample size, and was limited in scope, its results suggest that future research is warranted. Future studies using a larger sample size utilizing both a randomized control trial design and qualitative methods are needed to answer critical questions such as the role of patient characteristics on treatment effectiveness and the impact of the RESTORE model on long-term OUD medication adherence, patients’ perceptions and satisfaction, barriers to implementation, PCP confidence in providing pain care, and use of evidence-based nonpharmacologic pain management services.^12-14

Conclusions

The results of this quality-improvement project suggest that e-consults may facilitate referrals to and patient follow-through with evidence-based treatment for co-occurring chronic pain and OUD among veterans living in rural communities in Central Appalachia who tend to experience significant barriers to traditional care and may require an innovative approach to facilitate effective treatment.

Rural veterans are prescribed long-term opioid therapy for chronic pain at higher rates than urban veterans, increasing their risk of developing opioid use disorder (OUD).^1,2 Veterans with co-occurring OUD and chronic pain have more severe health concerns, as well as higher rates of homelessness, psychoactive drug misuse, and mental health disorders, compared to veterans with either chronic pain or OUD alone.³ Interdisciplinary team (IDT) care is recommended for both chronic pain and OUD.^4,5 Rural veterans with co-occurring chronic pain and OUD, however, are often unable to access IDTs due to long travel and wait times. As a result, these rural veterans often receive care from primary care practitioners (PCPs) who lack training in pain management and addiction and have low confidence in their ability to provide optimal treatment.^6,7

In the Veterans Health Administration, electronic consultations (e-consults) provide support to PCPs by recommending evidence-based approaches such as buprenorphine for OUD and pain IDTs for chronic pain.^5,8 However, research on the use of e-consults to connect to IDT care for co-occurring chronic pain and OUD are lacking, as well as studies on IDTs using innovative methods (eg, shared appointments) to overcome treatment barriers (eg, multiple appointments) for rural veterans at higher risk for co-occurring OUD and chronic pain. 

This quality improvement study sought to determine the feasibility and impact of a pharmacy e-consult service that provided pain medication recommendations and subsequent referrals to RESTORE, a shared appointment program with an IDT, for assessment and treatment of chronic pain and OUD.

Methods

This retrospective chart review was approved as nonresearch by the Institutional Review Board Chair at the Salem Veterans Affairs Healthcare System (SVAHS), a low-complexity medical center in Virginia that primarily serves a rural and highly rural Central Appalachian veteran population.

This study included veterans whose clinicians placed a pain medication e-consult requesting recommendations for medication adjustments and/or a referral to RESTORE from January 1, 2022, through January 6, 2023. Requests for services that could not be provided through an e-consult were excluded (Figure 1). Veterans who had a pain medication e-consult were identified in the SVAHS electronic medical record (EMR). Data extracted from the EMR included demographics, referral source, reason for referral, RESTORE appointment attendance, OUD diagnosis made during the RESTORE initial evaluation, implementation of medication recommendations by the referrer within 6 months, engagement in ≥ 3 pain education classes, and a shared appointment with a pain IDT within 6 months. Data were entered into a REDCap database, and descriptive statistics summarized the results. Feasibility was assessed by use of the e-consult by PCPs, attendance at the RESTORE appointment, and OUD diagnosis by the RESTORE team.

RESTORE Intervention

A pain medication e-consult was followed by referral to a shared appointment with the RESTORE IDT, with subsequent referrals to a pain IDT for chronic pain management if the veteran was amenable.

Pain medication e-consults in the EMR prompted a chart review by a clinical pharmacist practitioner (CPP). Recommendations for changes to medication regimens were documented in the EMR. At completion of the e-consult, the referring clinician received an automated view alert.

Veterans (and a support person, if preferred) were seen in a 60-minute, face-to-face shared appointment which included a psychologist, CPP, and pain physician. The psychologist conducted an OUD diagnostic interview, provided diagnostic feedback, and used motivational interviewing to provide psychoeducation on the biopsychosocial model of chronic pain, the IDT approach to chronic pain, and an overview of pain IDT care locally available. A CPP and physician then described medication options available to address OUD, if applicable. Together, the IDT and patient used shared decision making to determine a comprehensive treatment plan that may include a referral to the SVAHS PREVAIL Center for Chronic Pain IDT track (PREVAIL IDT track), a referral to substance use care in the case of polysubstance use, or medication initiation.^9-11 If medication was prescribed, the patient was subsequently followed by the CPP through phone calls and face-to-face appointments at regularly scheduled intervals in coordination with the prescriber until they were stabilized. After stabilization, the prescription would be managed by their PCP (Figure 2). Veterans whose clinical condition changed significantly or worsened after returning to their PCP were invited to be reevaluated by the RESTORE team and restart care in that program. Individuals who were actively receiving RESTORE team care were discussed in a weekly care coordination meeting with all clinicians from both the PREVAIL and RESTORE teams.

Program Metrics

Pain medication e-consults were placed for 77 patients; 7 were excluded as inappropriate referral requests. Seventy (83%) e-consults were placed by PCPs (Table). Fifty-seven referring PCPs (81%) implemented ≥ 1 medication recommendation and 41 (59%) implemented all recommendations within 6 months. CPPs referred 19 individuals to RESTORE due to concerns related to high risk. All attended the initial evaluation appointment with the RESTORE team, 17 (89%) agreed to be referred to PREVAIL IDT track for nonpharmacologic pain care, and 9 (53%) engaged with that care within 6 months. Of those who attended RESTORE, 7 patients (37%) initiated buprenorphine for OUD with 6 (86%) being prescribed buprenorphine for ≥ 6 months.

Discussion

Most e-consults placed at SVAHS, which primarily serves a rural veteran population in Central Appalachia, resulted in veterans engaging in evidence-based treatment for co-occurring chronic pain and OUD. The use of e-consults and subsequent shared appointments with an IDT appears to be feasible, as the service was most often used by PCPs who often feel unequipped to manage chronic pain.⁷ The attendance rate for the RESTORE appointments was notable given the typically poor follow-up for patients with OUD. It supports the feasibility of a shared appointment approach which may overcome frequent barriers to care in this vulnerable population (ie, time, transportation). By attending 1 appointment with all clinicians present as opposed to multiple appointments, veterans experience fewer barriers than attending multiple appointments. RESTORE continues to be offered as an active clinical service whose implementation is now supported by changes to SVAHS policies. Since this study was conducted, the number of patients seen weekly has doubled and will soon be tripled based on high demand from PCPs.

While this study was limited to 1 site, had a small sample size, and was limited in scope, its results suggest that future research is warranted. Future studies using a larger sample size utilizing both a randomized control trial design and qualitative methods are needed to answer critical questions such as the role of patient characteristics on treatment effectiveness and the impact of the RESTORE model on long-term OUD medication adherence, patients’ perceptions and satisfaction, barriers to implementation, PCP confidence in providing pain care, and use of evidence-based nonpharmacologic pain management services.^12-14

Conclusions

The results of this quality-improvement project suggest that e-consults may facilitate referrals to and patient follow-through with evidence-based treatment for co-occurring chronic pain and OUD among veterans living in rural communities in Central Appalachia who tend to experience significant barriers to traditional care and may require an innovative approach to facilitate effective treatment.

Rural veterans are prescribed long-term opioid therapy for chronic pain at higher rates than urban veterans, increasing their risk of developing opioid use disorder (OUD).^1,2 Veterans with co-occurring OUD and chronic pain have more severe health concerns, as well as higher rates of homelessness, psychoactive drug misuse, and mental health disorders, compared to veterans with either chronic pain or OUD alone.³ Interdisciplinary team (IDT) care is recommended for both chronic pain and OUD.^4,5 Rural veterans with co-occurring chronic pain and OUD, however, are often unable to access IDTs due to long travel and wait times. As a result, these rural veterans often receive care from primary care practitioners (PCPs) who lack training in pain management and addiction and have low confidence in their ability to provide optimal treatment.^6,7

In the Veterans Health Administration, electronic consultations (e-consults) provide support to PCPs by recommending evidence-based approaches such as buprenorphine for OUD and pain IDTs for chronic pain.^5,8 However, research on the use of e-consults to connect to IDT care for co-occurring chronic pain and OUD are lacking, as well as studies on IDTs using innovative methods (eg, shared appointments) to overcome treatment barriers (eg, multiple appointments) for rural veterans at higher risk for co-occurring OUD and chronic pain. 

This quality improvement study sought to determine the feasibility and impact of a pharmacy e-consult service that provided pain medication recommendations and subsequent referrals to RESTORE, a shared appointment program with an IDT, for assessment and treatment of chronic pain and OUD.

Methods

This retrospective chart review was approved as nonresearch by the Institutional Review Board Chair at the Salem Veterans Affairs Healthcare System (SVAHS), a low-complexity medical center in Virginia that primarily serves a rural and highly rural Central Appalachian veteran population.

This study included veterans whose clinicians placed a pain medication e-consult requesting recommendations for medication adjustments and/or a referral to RESTORE from January 1, 2022, through January 6, 2023. Requests for services that could not be provided through an e-consult were excluded (Figure 1). Veterans who had a pain medication e-consult were identified in the SVAHS electronic medical record (EMR). Data extracted from the EMR included demographics, referral source, reason for referral, RESTORE appointment attendance, OUD diagnosis made during the RESTORE initial evaluation, implementation of medication recommendations by the referrer within 6 months, engagement in ≥ 3 pain education classes, and a shared appointment with a pain IDT within 6 months. Data were entered into a REDCap database, and descriptive statistics summarized the results. Feasibility was assessed by use of the e-consult by PCPs, attendance at the RESTORE appointment, and OUD diagnosis by the RESTORE team.

RESTORE Intervention

A pain medication e-consult was followed by referral to a shared appointment with the RESTORE IDT, with subsequent referrals to a pain IDT for chronic pain management if the veteran was amenable.

Pain medication e-consults in the EMR prompted a chart review by a clinical pharmacist practitioner (CPP). Recommendations for changes to medication regimens were documented in the EMR. At completion of the e-consult, the referring clinician received an automated view alert.

Veterans (and a support person, if preferred) were seen in a 60-minute, face-to-face shared appointment which included a psychologist, CPP, and pain physician. The psychologist conducted an OUD diagnostic interview, provided diagnostic feedback, and used motivational interviewing to provide psychoeducation on the biopsychosocial model of chronic pain, the IDT approach to chronic pain, and an overview of pain IDT care locally available. A CPP and physician then described medication options available to address OUD, if applicable. Together, the IDT and patient used shared decision making to determine a comprehensive treatment plan that may include a referral to the SVAHS PREVAIL Center for Chronic Pain IDT track (PREVAIL IDT track), a referral to substance use care in the case of polysubstance use, or medication initiation.^9-11 If medication was prescribed, the patient was subsequently followed by the CPP through phone calls and face-to-face appointments at regularly scheduled intervals in coordination with the prescriber until they were stabilized. After stabilization, the prescription would be managed by their PCP (Figure 2). Veterans whose clinical condition changed significantly or worsened after returning to their PCP were invited to be reevaluated by the RESTORE team and restart care in that program. Individuals who were actively receiving RESTORE team care were discussed in a weekly care coordination meeting with all clinicians from both the PREVAIL and RESTORE teams.

Program Metrics

Pain medication e-consults were placed for 77 patients; 7 were excluded as inappropriate referral requests. Seventy (83%) e-consults were placed by PCPs (Table). Fifty-seven referring PCPs (81%) implemented ≥ 1 medication recommendation and 41 (59%) implemented all recommendations within 6 months. CPPs referred 19 individuals to RESTORE due to concerns related to high risk. All attended the initial evaluation appointment with the RESTORE team, 17 (89%) agreed to be referred to PREVAIL IDT track for nonpharmacologic pain care, and 9 (53%) engaged with that care within 6 months. Of those who attended RESTORE, 7 patients (37%) initiated buprenorphine for OUD with 6 (86%) being prescribed buprenorphine for ≥ 6 months.

Discussion

Most e-consults placed at SVAHS, which primarily serves a rural veteran population in Central Appalachia, resulted in veterans engaging in evidence-based treatment for co-occurring chronic pain and OUD. The use of e-consults and subsequent shared appointments with an IDT appears to be feasible, as the service was most often used by PCPs who often feel unequipped to manage chronic pain.⁷ The attendance rate for the RESTORE appointments was notable given the typically poor follow-up for patients with OUD. It supports the feasibility of a shared appointment approach which may overcome frequent barriers to care in this vulnerable population (ie, time, transportation). By attending 1 appointment with all clinicians present as opposed to multiple appointments, veterans experience fewer barriers than attending multiple appointments. RESTORE continues to be offered as an active clinical service whose implementation is now supported by changes to SVAHS policies. Since this study was conducted, the number of patients seen weekly has doubled and will soon be tripled based on high demand from PCPs.

While this study was limited to 1 site, had a small sample size, and was limited in scope, its results suggest that future research is warranted. Future studies using a larger sample size utilizing both a randomized control trial design and qualitative methods are needed to answer critical questions such as the role of patient characteristics on treatment effectiveness and the impact of the RESTORE model on long-term OUD medication adherence, patients’ perceptions and satisfaction, barriers to implementation, PCP confidence in providing pain care, and use of evidence-based nonpharmacologic pain management services.^12-14

Conclusions

The results of this quality-improvement project suggest that e-consults may facilitate referrals to and patient follow-through with evidence-based treatment for co-occurring chronic pain and OUD among veterans living in rural communities in Central Appalachia who tend to experience significant barriers to traditional care and may require an innovative approach to facilitate effective treatment.

Safety event reporting plays a vital role in fostering a culture of safety within a health care organization. The US Department of Veterans Affairs (VA) has shifted its focus from eradicating medical errors to minimizing or eliminating harm to patients.¹ The National Center for Patient Safety’s objective is to prevent recurring errors by identifying and addressing systemic problems that may have been overlooked.²

Taking inspiration from industries known for high reliability, such as aviation and nuclear power, the Veterans Health Administration (VHA) patient safety program aims to identify and eliminate system vulnerabilities, such as medical errors. Learning from near misses, which occur more frequently than actual adverse events, is a crucial part of this process.³ By addressing these issues, the VHA can establish safer systems and encourage continuous identification of potential problems with proactive resolution. 

All staff should participate actively in event reporting, which involves documenting and communicating details, outcomes, and relevant data about an event to understand what occurred, evaluate success, identify areas for improvement, and inform future decisions. This helps identify system weaknesses, create opportunities to standardize procedures and enhance patient care.

At the high complexity Central Texas Veterans Health Care System (CTVHCS), the fiscal year (FY) 2023 All Employee Survey (AES) found that staff members require additional education and awareness regarding the reporting of patient safety concerns.⁴ The survey highlighted areas such as lack of education on reporting, doubts about the effectiveness of reporting, confusion about the process after a report is made, and insufficient feedback.

BACKGROUND

To improve the culture of safety and address deficiencies noted in the AES, the CTVHCS patient safety (PS) and high reliability organization (HRO) teams partnered to develop a quality improvement initiative to increase staff understanding of safety event reporting and strengthen the safety culture. The PS and HRO teams developed an innovative education model that integrates Joint Patient Safety Reporting System (JPSR) education into huddles.

This initiative, called the JPSR Huddle Card Toolkit, sought to assess the impact of the toolkit on staff knowledge and behaviors related to patient safety event reporting. The toolkit consisted of educational materials encompassing 6 key areas: (1) reporting incidents; (2) close calls and near misses; (3) identification of root causes; (4) understanding the life cycle of a JPSR; (5) celebrating achievements; and (6) distinguishing between facts and fiction. Each JPSR huddle card included discussion points for the facilitator and was formatted on a 5 × 7-inch card (Figure 1). Topics were addressed during weekly safety huddles conducted in the pilot unit over a 6-week period. To evaluate its effectiveness, a pilot unit was selected and distributed an anonymous questionnaire paired with the JPSR huddle card toolkit to measure staff responses. 

The pilot was conducted from November 2023 to January 2024. The participating pilot unit was a 10-bed critical care unit with 42 full-time employees. Nursing leadership, quality safety, and value personnel, and the Veterans Integrated Services Network (VISN) PS Team reviewed and approved the pilot.

Reporting of adverse events and near misses provides an opportunity to learn about latent systems errors.² In 2018, the VHA began using the JPSR to standardize the capture and data management on medical errors and close calls across the Defense Health Administration (DHA) and VHA.¹ The JPSR software is a joint application of the VHA and DHA. It improves the identification and documentation of patient safety-related events for VA medical centers, military hospitals and clinics, active-duty personnel, veterans and their families. 

Event reporting is a key element in advancing high reliability and achieving zero preventable harm.¹ Teams use these data to identify organizational patient safety trends and preempt common safety issues. All data are protected under 38 USC §5705 and 10 USC §1102.⁵ The JPSR single-source system standardizes the collection of core data points and increases collaboration between the DHA and VHA. This partnership increases insight into safety-related incidents, allowing for earlier detection and prevention of patient harm or injury incidents.

Numerous studies consistently commend huddles for their effectiveness in promoting teamwork and their positive impact on patient safety.^6-8 Huddles facilitate connections between employees who may not typically interact, provide opportunities for discussions, and serve as a platform to encourage employees to voice their opinions. By fostering these interactions, huddles empower employees and create an environment for shared understanding, building trust, and promoting continuous learning.⁸

OBSERVATIONS

The JPSR huddle card initiative aimed to improve understanding of the JPSR process and promote knowledge and attitudes about patient safety and event reporting, while emphasizing shared responsibility. The goals focused on effective communication, respect for expertise, awareness of operational nuances, voicing concerns, and ensuring zero harm.

The facilitator initiated huddles by announcing their start to cultivate a constructive outcome.⁸ The JPSR huddle cards used a structured format designed to foster engagement and understanding of the topic. Each card begins with a factual statement or an open-ended question to gauge participants’ awareness or understanding. It then provides essential facts, principles, and relevant information to deepen knowledge. The card concludes with a discussion question, allowing facilitators to assess shared learning and encourage group reflection. This format promotes active participation and ensures that key concepts are both introduced and reinforced through dialogue.

The PS team standardized the format for all huddle cards, allowing 5 to 10 minutes for discussing training materials, receiving feedback, and concluding with a discussion question and call to action. Prior to each huddle, the facilitator would read a scripted remark that reviewed the objectives and ground rules for an effective huddle. 

The PS and HRO teams promoted interactive discussions and welcomed ongoing feedback. Huddles provided a psychologically safe environment where individuals were encouraged to voice their thoughts and ideas.

Each weekly huddle card addressed a different patient safety topic. The Week 1 huddle card focuses on event reporting for safety improvement. The card outlines the purpose of JPSR as a tool to identify, manage, and analyze safety events to reduce preventable harm. The card emphasizes 3 core principles: (1) acknowledging mistakes, recognizing that errors happen; (2) no blame, no shame (encouraging a no-blame just culture to raise concerns); and (3) continuous improvement (committing to ongoing learning and prevention). It provides guidance on event details entry, advising staff to include facts in an SBAR (Situation, Background, Assessment, Response) format, avoid assumptions, and exclude personal identifiers. Tips include entering only relevant facts to help reviewers understand the incident. The card ends with discussion questions on reporting barriers and potential improvements in event reporting practices.

The Week 2 huddle card focuses on understanding and reporting near miss events, also known as close calls or good catches. A near miss is an incident where a potential hazard was identified and prevented before it reached the patient, avoiding harm due to timely intervention. The card emphasizes the importance of identifying these events to understand weaknesses and proactively reduce risks. Examples of near misses include discovering expired medication before use, catching a potential wrong-site surgery, and noticing incorrect medication dosages. Staff are encouraged to develop a mindset for anticipating and solving risks. The card ends with a discussion asking participants to share examples of near misses in their area.

The Week 3 huddle card covers root causes in preventing errors. The card highlights that errors in health care often stem from flawed processes rather than individual faults. By identifying root causes, systemic weaknesses can be addressed to reduce mistakes and build more error-tolerant and robust systems. All staff are advised to adopt a mindset of continuous improvement, error trapping behaviors and problem-solving. It concludes with discussion questions prompting reflection on assumptions and identifying weaknesses when something goes wrong.

The Week 4 huddle card covers the life of a JPSR, detailing that after entry JPSR events are viewed by the highest leadership levels at the morning report, and that lessons learned are distributed through frontline managers and chiefs in a monthly report to be shared with frontline staff. Additionally, JPSR trends are shared during monthly HRO safety forums. These practices promote a culture of safety through open communication and problem-solving. Staff and leaders are encouraged to prioritize safety daily. Discussion prompts ask team members if they had seen positive changes from JPSR reporting and what they would like leadership to communicate after investigations.

The Week 5 huddle card covers celebrating safety event reporting called Cue the Confetti. The VHA emphasizes recognizing staff who report safety events as part of their commitment to zero harm. By celebrating these contributions, the VHA fosters respect, joy, and satisfaction in the work. Staff are encouraged to nominate colleagues for recognition, reinforcing a supportive environment. Prompts invite teams to discuss how they celebrate JPSR reporting and how they’d like to enhance this culture of appreciation.

The Week 6 huddle card covers common misconceptions about JPSR. Key facts include that JPSRs are confidential, not for disciplinary action, and can be submitted by any staff member at any time. Only PS can view reporter identities for clarification purposes. The card concludes with prompts to ensure staff know how to access JPSR support and resources.

Measuring the impact on staff was essential to assess effectiveness and gather data for program improvement. To evaluate the impact of the huddle cards on the staff, the team provided a voluntary and anonymous 9 question survey (Figure 2). The survey was completed before the pilot began and again at the end of Week 6. 

Questions 1 through 5 and 7 through 9 pertained to participants’ perceived knowledge and understanding of aspects of the JPSR. Perceived improvement among intensive care unit (ICU) participants ranged from 15% to 53%. There was a positive increase associated with every question with the top improvements: question 8, “How do you rate your understanding of how we share safety events for system and process improvement?” (53.4% increase); question 5, “How do you rate your understanding of what happens to a JPSR after it is entered?” (51.9% increase), and question 9, “How do you rate your understanding of the concepts of trust, psychological safety and a just culture?” (47.8% increase).

The survey analysis was not able to track individual changes. As a result, the findings reflect an overall change for the entire study group. Moreover, the questions assessed participants’ perceived knowledge rather than actual knowledge gained. It is important to note that there may be a significant gap between the actual knowledge gained and how participants perceive it. Additionally, improvement in knowledge and comprehension does not necessarily translate into behavior changes.

CONCLUSIONS

The use of JPSR huddle cards and direct engagement with staff during safety huddles yielded positive outcomes. On average, participants demonstrated higher scores in posttest questions compared to pretest questions. The posttest scores were consistently higher than the pretest scores, showing an average increase of around 2 standard deviations across all questions. This indicates an improvement in participants’ perceived knowledge and comprehension of the JPSR material.

During the pilot implementation of the huddle cards, there was a notable improvement in team member engagement. The structured format of the cards facilitated focused and meaningful discussions during safety huddles, encouraging open dialogue and fostering a culture of safety. Team members actively participated in identifying potential risks, sharing observations, and proposing actionable solutions, which reflected an enhanced sense of ownership regarding safety practices.

The support dialogue facilitated by the huddle cards highlighted the significance of mutual accountability and a collective commitment to achieving zero harm. This collaborative environment strengthened trust among team members and underscored the importance of shared vigilance in preventing adverse events. The pilot demonstrated the potential of huddle cards as an essential tool for enhancing team-based safety initiatives and promoting a culture of high reliability within the organization.

The total number of JPSR events in the ICU rose from 156 in FY 23 to 170 in FY 24. Adverse events increased from 19 to 31, while close calls saw a slight uptick from 137 to 139. Despite the overall rise in adverse events, a detailed analysis indicated that incidents of moderate harm decreased from 4 in FY 23 to 2 in FY 24. Furthermore, there was 1 reported case of death or severe harm in FY 23, which decreased to 0 in FY 24. This trend is consistent with the overarching objective of a high-reliability organization to achieve zero harm.

The next step is to expand this initiative across CTVHCS. This initiative aims to make this an annual education for all areas. The JPSR huddle card toolkit will be formatted by the media department for easy printing and retrieval. Leaders within units, clinics, and services will be empowered to facilitate the sessions in their safety huddles and reap the same outcomes as in the pilot. CTVHCS PS will monitor the effectiveness of this through ongoing CTVHCS patient safety rounding and future AES.

Safety event reporting plays a vital role in fostering a culture of safety within a health care organization. The US Department of Veterans Affairs (VA) has shifted its focus from eradicating medical errors to minimizing or eliminating harm to patients.¹ The National Center for Patient Safety’s objective is to prevent recurring errors by identifying and addressing systemic problems that may have been overlooked.²

Taking inspiration from industries known for high reliability, such as aviation and nuclear power, the Veterans Health Administration (VHA) patient safety program aims to identify and eliminate system vulnerabilities, such as medical errors. Learning from near misses, which occur more frequently than actual adverse events, is a crucial part of this process.³ By addressing these issues, the VHA can establish safer systems and encourage continuous identification of potential problems with proactive resolution. 

All staff should participate actively in event reporting, which involves documenting and communicating details, outcomes, and relevant data about an event to understand what occurred, evaluate success, identify areas for improvement, and inform future decisions. This helps identify system weaknesses, create opportunities to standardize procedures and enhance patient care.

At the high complexity Central Texas Veterans Health Care System (CTVHCS), the fiscal year (FY) 2023 All Employee Survey (AES) found that staff members require additional education and awareness regarding the reporting of patient safety concerns.⁴ The survey highlighted areas such as lack of education on reporting, doubts about the effectiveness of reporting, confusion about the process after a report is made, and insufficient feedback.

BACKGROUND

To improve the culture of safety and address deficiencies noted in the AES, the CTVHCS patient safety (PS) and high reliability organization (HRO) teams partnered to develop a quality improvement initiative to increase staff understanding of safety event reporting and strengthen the safety culture. The PS and HRO teams developed an innovative education model that integrates Joint Patient Safety Reporting System (JPSR) education into huddles.

This initiative, called the JPSR Huddle Card Toolkit, sought to assess the impact of the toolkit on staff knowledge and behaviors related to patient safety event reporting. The toolkit consisted of educational materials encompassing 6 key areas: (1) reporting incidents; (2) close calls and near misses; (3) identification of root causes; (4) understanding the life cycle of a JPSR; (5) celebrating achievements; and (6) distinguishing between facts and fiction. Each JPSR huddle card included discussion points for the facilitator and was formatted on a 5 × 7-inch card (Figure 1). Topics were addressed during weekly safety huddles conducted in the pilot unit over a 6-week period. To evaluate its effectiveness, a pilot unit was selected and distributed an anonymous questionnaire paired with the JPSR huddle card toolkit to measure staff responses. 

The pilot was conducted from November 2023 to January 2024. The participating pilot unit was a 10-bed critical care unit with 42 full-time employees. Nursing leadership, quality safety, and value personnel, and the Veterans Integrated Services Network (VISN) PS Team reviewed and approved the pilot.

Reporting of adverse events and near misses provides an opportunity to learn about latent systems errors.² In 2018, the VHA began using the JPSR to standardize the capture and data management on medical errors and close calls across the Defense Health Administration (DHA) and VHA.¹ The JPSR software is a joint application of the VHA and DHA. It improves the identification and documentation of patient safety-related events for VA medical centers, military hospitals and clinics, active-duty personnel, veterans and their families. 

Event reporting is a key element in advancing high reliability and achieving zero preventable harm.¹ Teams use these data to identify organizational patient safety trends and preempt common safety issues. All data are protected under 38 USC §5705 and 10 USC §1102.⁵ The JPSR single-source system standardizes the collection of core data points and increases collaboration between the DHA and VHA. This partnership increases insight into safety-related incidents, allowing for earlier detection and prevention of patient harm or injury incidents.

Numerous studies consistently commend huddles for their effectiveness in promoting teamwork and their positive impact on patient safety.^6-8 Huddles facilitate connections between employees who may not typically interact, provide opportunities for discussions, and serve as a platform to encourage employees to voice their opinions. By fostering these interactions, huddles empower employees and create an environment for shared understanding, building trust, and promoting continuous learning.⁸

OBSERVATIONS

The JPSR huddle card initiative aimed to improve understanding of the JPSR process and promote knowledge and attitudes about patient safety and event reporting, while emphasizing shared responsibility. The goals focused on effective communication, respect for expertise, awareness of operational nuances, voicing concerns, and ensuring zero harm.

The facilitator initiated huddles by announcing their start to cultivate a constructive outcome.⁸ The JPSR huddle cards used a structured format designed to foster engagement and understanding of the topic. Each card begins with a factual statement or an open-ended question to gauge participants’ awareness or understanding. It then provides essential facts, principles, and relevant information to deepen knowledge. The card concludes with a discussion question, allowing facilitators to assess shared learning and encourage group reflection. This format promotes active participation and ensures that key concepts are both introduced and reinforced through dialogue.

The PS team standardized the format for all huddle cards, allowing 5 to 10 minutes for discussing training materials, receiving feedback, and concluding with a discussion question and call to action. Prior to each huddle, the facilitator would read a scripted remark that reviewed the objectives and ground rules for an effective huddle. 

The PS and HRO teams promoted interactive discussions and welcomed ongoing feedback. Huddles provided a psychologically safe environment where individuals were encouraged to voice their thoughts and ideas.

Each weekly huddle card addressed a different patient safety topic. The Week 1 huddle card focuses on event reporting for safety improvement. The card outlines the purpose of JPSR as a tool to identify, manage, and analyze safety events to reduce preventable harm. The card emphasizes 3 core principles: (1) acknowledging mistakes, recognizing that errors happen; (2) no blame, no shame (encouraging a no-blame just culture to raise concerns); and (3) continuous improvement (committing to ongoing learning and prevention). It provides guidance on event details entry, advising staff to include facts in an SBAR (Situation, Background, Assessment, Response) format, avoid assumptions, and exclude personal identifiers. Tips include entering only relevant facts to help reviewers understand the incident. The card ends with discussion questions on reporting barriers and potential improvements in event reporting practices.

The Week 2 huddle card focuses on understanding and reporting near miss events, also known as close calls or good catches. A near miss is an incident where a potential hazard was identified and prevented before it reached the patient, avoiding harm due to timely intervention. The card emphasizes the importance of identifying these events to understand weaknesses and proactively reduce risks. Examples of near misses include discovering expired medication before use, catching a potential wrong-site surgery, and noticing incorrect medication dosages. Staff are encouraged to develop a mindset for anticipating and solving risks. The card ends with a discussion asking participants to share examples of near misses in their area.

The Week 3 huddle card covers root causes in preventing errors. The card highlights that errors in health care often stem from flawed processes rather than individual faults. By identifying root causes, systemic weaknesses can be addressed to reduce mistakes and build more error-tolerant and robust systems. All staff are advised to adopt a mindset of continuous improvement, error trapping behaviors and problem-solving. It concludes with discussion questions prompting reflection on assumptions and identifying weaknesses when something goes wrong.

The Week 4 huddle card covers the life of a JPSR, detailing that after entry JPSR events are viewed by the highest leadership levels at the morning report, and that lessons learned are distributed through frontline managers and chiefs in a monthly report to be shared with frontline staff. Additionally, JPSR trends are shared during monthly HRO safety forums. These practices promote a culture of safety through open communication and problem-solving. Staff and leaders are encouraged to prioritize safety daily. Discussion prompts ask team members if they had seen positive changes from JPSR reporting and what they would like leadership to communicate after investigations.

The Week 5 huddle card covers celebrating safety event reporting called Cue the Confetti. The VHA emphasizes recognizing staff who report safety events as part of their commitment to zero harm. By celebrating these contributions, the VHA fosters respect, joy, and satisfaction in the work. Staff are encouraged to nominate colleagues for recognition, reinforcing a supportive environment. Prompts invite teams to discuss how they celebrate JPSR reporting and how they’d like to enhance this culture of appreciation.

The Week 6 huddle card covers common misconceptions about JPSR. Key facts include that JPSRs are confidential, not for disciplinary action, and can be submitted by any staff member at any time. Only PS can view reporter identities for clarification purposes. The card concludes with prompts to ensure staff know how to access JPSR support and resources.

Measuring the impact on staff was essential to assess effectiveness and gather data for program improvement. To evaluate the impact of the huddle cards on the staff, the team provided a voluntary and anonymous 9 question survey (Figure 2). The survey was completed before the pilot began and again at the end of Week 6. 

Questions 1 through 5 and 7 through 9 pertained to participants’ perceived knowledge and understanding of aspects of the JPSR. Perceived improvement among intensive care unit (ICU) participants ranged from 15% to 53%. There was a positive increase associated with every question with the top improvements: question 8, “How do you rate your understanding of how we share safety events for system and process improvement?” (53.4% increase); question 5, “How do you rate your understanding of what happens to a JPSR after it is entered?” (51.9% increase), and question 9, “How do you rate your understanding of the concepts of trust, psychological safety and a just culture?” (47.8% increase).

The survey analysis was not able to track individual changes. As a result, the findings reflect an overall change for the entire study group. Moreover, the questions assessed participants’ perceived knowledge rather than actual knowledge gained. It is important to note that there may be a significant gap between the actual knowledge gained and how participants perceive it. Additionally, improvement in knowledge and comprehension does not necessarily translate into behavior changes.

CONCLUSIONS

The use of JPSR huddle cards and direct engagement with staff during safety huddles yielded positive outcomes. On average, participants demonstrated higher scores in posttest questions compared to pretest questions. The posttest scores were consistently higher than the pretest scores, showing an average increase of around 2 standard deviations across all questions. This indicates an improvement in participants’ perceived knowledge and comprehension of the JPSR material.

During the pilot implementation of the huddle cards, there was a notable improvement in team member engagement. The structured format of the cards facilitated focused and meaningful discussions during safety huddles, encouraging open dialogue and fostering a culture of safety. Team members actively participated in identifying potential risks, sharing observations, and proposing actionable solutions, which reflected an enhanced sense of ownership regarding safety practices.

The support dialogue facilitated by the huddle cards highlighted the significance of mutual accountability and a collective commitment to achieving zero harm. This collaborative environment strengthened trust among team members and underscored the importance of shared vigilance in preventing adverse events. The pilot demonstrated the potential of huddle cards as an essential tool for enhancing team-based safety initiatives and promoting a culture of high reliability within the organization.

The total number of JPSR events in the ICU rose from 156 in FY 23 to 170 in FY 24. Adverse events increased from 19 to 31, while close calls saw a slight uptick from 137 to 139. Despite the overall rise in adverse events, a detailed analysis indicated that incidents of moderate harm decreased from 4 in FY 23 to 2 in FY 24. Furthermore, there was 1 reported case of death or severe harm in FY 23, which decreased to 0 in FY 24. This trend is consistent with the overarching objective of a high-reliability organization to achieve zero harm.

The next step is to expand this initiative across CTVHCS. This initiative aims to make this an annual education for all areas. The JPSR huddle card toolkit will be formatted by the media department for easy printing and retrieval. Leaders within units, clinics, and services will be empowered to facilitate the sessions in their safety huddles and reap the same outcomes as in the pilot. CTVHCS PS will monitor the effectiveness of this through ongoing CTVHCS patient safety rounding and future AES.

Safety event reporting plays a vital role in fostering a culture of safety within a health care organization. The US Department of Veterans Affairs (VA) has shifted its focus from eradicating medical errors to minimizing or eliminating harm to patients.¹ The National Center for Patient Safety’s objective is to prevent recurring errors by identifying and addressing systemic problems that may have been overlooked.²

Taking inspiration from industries known for high reliability, such as aviation and nuclear power, the Veterans Health Administration (VHA) patient safety program aims to identify and eliminate system vulnerabilities, such as medical errors. Learning from near misses, which occur more frequently than actual adverse events, is a crucial part of this process.³ By addressing these issues, the VHA can establish safer systems and encourage continuous identification of potential problems with proactive resolution. 

All staff should participate actively in event reporting, which involves documenting and communicating details, outcomes, and relevant data about an event to understand what occurred, evaluate success, identify areas for improvement, and inform future decisions. This helps identify system weaknesses, create opportunities to standardize procedures and enhance patient care.

At the high complexity Central Texas Veterans Health Care System (CTVHCS), the fiscal year (FY) 2023 All Employee Survey (AES) found that staff members require additional education and awareness regarding the reporting of patient safety concerns.⁴ The survey highlighted areas such as lack of education on reporting, doubts about the effectiveness of reporting, confusion about the process after a report is made, and insufficient feedback.

BACKGROUND

To improve the culture of safety and address deficiencies noted in the AES, the CTVHCS patient safety (PS) and high reliability organization (HRO) teams partnered to develop a quality improvement initiative to increase staff understanding of safety event reporting and strengthen the safety culture. The PS and HRO teams developed an innovative education model that integrates Joint Patient Safety Reporting System (JPSR) education into huddles.

This initiative, called the JPSR Huddle Card Toolkit, sought to assess the impact of the toolkit on staff knowledge and behaviors related to patient safety event reporting. The toolkit consisted of educational materials encompassing 6 key areas: (1) reporting incidents; (2) close calls and near misses; (3) identification of root causes; (4) understanding the life cycle of a JPSR; (5) celebrating achievements; and (6) distinguishing between facts and fiction. Each JPSR huddle card included discussion points for the facilitator and was formatted on a 5 × 7-inch card (Figure 1). Topics were addressed during weekly safety huddles conducted in the pilot unit over a 6-week period. To evaluate its effectiveness, a pilot unit was selected and distributed an anonymous questionnaire paired with the JPSR huddle card toolkit to measure staff responses. 

The pilot was conducted from November 2023 to January 2024. The participating pilot unit was a 10-bed critical care unit with 42 full-time employees. Nursing leadership, quality safety, and value personnel, and the Veterans Integrated Services Network (VISN) PS Team reviewed and approved the pilot.

Reporting of adverse events and near misses provides an opportunity to learn about latent systems errors.² In 2018, the VHA began using the JPSR to standardize the capture and data management on medical errors and close calls across the Defense Health Administration (DHA) and VHA.¹ The JPSR software is a joint application of the VHA and DHA. It improves the identification and documentation of patient safety-related events for VA medical centers, military hospitals and clinics, active-duty personnel, veterans and their families. 

Event reporting is a key element in advancing high reliability and achieving zero preventable harm.¹ Teams use these data to identify organizational patient safety trends and preempt common safety issues. All data are protected under 38 USC §5705 and 10 USC §1102.⁵ The JPSR single-source system standardizes the collection of core data points and increases collaboration between the DHA and VHA. This partnership increases insight into safety-related incidents, allowing for earlier detection and prevention of patient harm or injury incidents.

Numerous studies consistently commend huddles for their effectiveness in promoting teamwork and their positive impact on patient safety.^6-8 Huddles facilitate connections between employees who may not typically interact, provide opportunities for discussions, and serve as a platform to encourage employees to voice their opinions. By fostering these interactions, huddles empower employees and create an environment for shared understanding, building trust, and promoting continuous learning.⁸

OBSERVATIONS

The JPSR huddle card initiative aimed to improve understanding of the JPSR process and promote knowledge and attitudes about patient safety and event reporting, while emphasizing shared responsibility. The goals focused on effective communication, respect for expertise, awareness of operational nuances, voicing concerns, and ensuring zero harm.

The facilitator initiated huddles by announcing their start to cultivate a constructive outcome.⁸ The JPSR huddle cards used a structured format designed to foster engagement and understanding of the topic. Each card begins with a factual statement or an open-ended question to gauge participants’ awareness or understanding. It then provides essential facts, principles, and relevant information to deepen knowledge. The card concludes with a discussion question, allowing facilitators to assess shared learning and encourage group reflection. This format promotes active participation and ensures that key concepts are both introduced and reinforced through dialogue.

The PS team standardized the format for all huddle cards, allowing 5 to 10 minutes for discussing training materials, receiving feedback, and concluding with a discussion question and call to action. Prior to each huddle, the facilitator would read a scripted remark that reviewed the objectives and ground rules for an effective huddle. 

The PS and HRO teams promoted interactive discussions and welcomed ongoing feedback. Huddles provided a psychologically safe environment where individuals were encouraged to voice their thoughts and ideas.

Each weekly huddle card addressed a different patient safety topic. The Week 1 huddle card focuses on event reporting for safety improvement. The card outlines the purpose of JPSR as a tool to identify, manage, and analyze safety events to reduce preventable harm. The card emphasizes 3 core principles: (1) acknowledging mistakes, recognizing that errors happen; (2) no blame, no shame (encouraging a no-blame just culture to raise concerns); and (3) continuous improvement (committing to ongoing learning and prevention). It provides guidance on event details entry, advising staff to include facts in an SBAR (Situation, Background, Assessment, Response) format, avoid assumptions, and exclude personal identifiers. Tips include entering only relevant facts to help reviewers understand the incident. The card ends with discussion questions on reporting barriers and potential improvements in event reporting practices.

The Week 2 huddle card focuses on understanding and reporting near miss events, also known as close calls or good catches. A near miss is an incident where a potential hazard was identified and prevented before it reached the patient, avoiding harm due to timely intervention. The card emphasizes the importance of identifying these events to understand weaknesses and proactively reduce risks. Examples of near misses include discovering expired medication before use, catching a potential wrong-site surgery, and noticing incorrect medication dosages. Staff are encouraged to develop a mindset for anticipating and solving risks. The card ends with a discussion asking participants to share examples of near misses in their area.

The Week 3 huddle card covers root causes in preventing errors. The card highlights that errors in health care often stem from flawed processes rather than individual faults. By identifying root causes, systemic weaknesses can be addressed to reduce mistakes and build more error-tolerant and robust systems. All staff are advised to adopt a mindset of continuous improvement, error trapping behaviors and problem-solving. It concludes with discussion questions prompting reflection on assumptions and identifying weaknesses when something goes wrong.

The Week 4 huddle card covers the life of a JPSR, detailing that after entry JPSR events are viewed by the highest leadership levels at the morning report, and that lessons learned are distributed through frontline managers and chiefs in a monthly report to be shared with frontline staff. Additionally, JPSR trends are shared during monthly HRO safety forums. These practices promote a culture of safety through open communication and problem-solving. Staff and leaders are encouraged to prioritize safety daily. Discussion prompts ask team members if they had seen positive changes from JPSR reporting and what they would like leadership to communicate after investigations.

The Week 5 huddle card covers celebrating safety event reporting called Cue the Confetti. The VHA emphasizes recognizing staff who report safety events as part of their commitment to zero harm. By celebrating these contributions, the VHA fosters respect, joy, and satisfaction in the work. Staff are encouraged to nominate colleagues for recognition, reinforcing a supportive environment. Prompts invite teams to discuss how they celebrate JPSR reporting and how they’d like to enhance this culture of appreciation.

The Week 6 huddle card covers common misconceptions about JPSR. Key facts include that JPSRs are confidential, not for disciplinary action, and can be submitted by any staff member at any time. Only PS can view reporter identities for clarification purposes. The card concludes with prompts to ensure staff know how to access JPSR support and resources.

Measuring the impact on staff was essential to assess effectiveness and gather data for program improvement. To evaluate the impact of the huddle cards on the staff, the team provided a voluntary and anonymous 9 question survey (Figure 2). The survey was completed before the pilot began and again at the end of Week 6. 

Questions 1 through 5 and 7 through 9 pertained to participants’ perceived knowledge and understanding of aspects of the JPSR. Perceived improvement among intensive care unit (ICU) participants ranged from 15% to 53%. There was a positive increase associated with every question with the top improvements: question 8, “How do you rate your understanding of how we share safety events for system and process improvement?” (53.4% increase); question 5, “How do you rate your understanding of what happens to a JPSR after it is entered?” (51.9% increase), and question 9, “How do you rate your understanding of the concepts of trust, psychological safety and a just culture?” (47.8% increase).

The survey analysis was not able to track individual changes. As a result, the findings reflect an overall change for the entire study group. Moreover, the questions assessed participants’ perceived knowledge rather than actual knowledge gained. It is important to note that there may be a significant gap between the actual knowledge gained and how participants perceive it. Additionally, improvement in knowledge and comprehension does not necessarily translate into behavior changes.

CONCLUSIONS

The use of JPSR huddle cards and direct engagement with staff during safety huddles yielded positive outcomes. On average, participants demonstrated higher scores in posttest questions compared to pretest questions. The posttest scores were consistently higher than the pretest scores, showing an average increase of around 2 standard deviations across all questions. This indicates an improvement in participants’ perceived knowledge and comprehension of the JPSR material.

During the pilot implementation of the huddle cards, there was a notable improvement in team member engagement. The structured format of the cards facilitated focused and meaningful discussions during safety huddles, encouraging open dialogue and fostering a culture of safety. Team members actively participated in identifying potential risks, sharing observations, and proposing actionable solutions, which reflected an enhanced sense of ownership regarding safety practices.

The support dialogue facilitated by the huddle cards highlighted the significance of mutual accountability and a collective commitment to achieving zero harm. This collaborative environment strengthened trust among team members and underscored the importance of shared vigilance in preventing adverse events. The pilot demonstrated the potential of huddle cards as an essential tool for enhancing team-based safety initiatives and promoting a culture of high reliability within the organization.

The total number of JPSR events in the ICU rose from 156 in FY 23 to 170 in FY 24. Adverse events increased from 19 to 31, while close calls saw a slight uptick from 137 to 139. Despite the overall rise in adverse events, a detailed analysis indicated that incidents of moderate harm decreased from 4 in FY 23 to 2 in FY 24. Furthermore, there was 1 reported case of death or severe harm in FY 23, which decreased to 0 in FY 24. This trend is consistent with the overarching objective of a high-reliability organization to achieve zero harm.

The next step is to expand this initiative across CTVHCS. This initiative aims to make this an annual education for all areas. The JPSR huddle card toolkit will be formatted by the media department for easy printing and retrieval. Leaders within units, clinics, and services will be empowered to facilitate the sessions in their safety huddles and reap the same outcomes as in the pilot. CTVHCS PS will monitor the effectiveness of this through ongoing CTVHCS patient safety rounding and future AES.