• Marcia M Piotrowski, Sanjay Saint, and Daniel B Hinshaw.
• VA Ann Arbor Healthcare System (VAAAHS), Ann Arbor, Michigan, USA. Marcia.Piotrowski@med.va.gov
• Jt Comm J Qual Improv. 2002 Jun 1; 28 (6): 296-305.

BackgroundThe greatest gains in patient safety are likely to result from using a multifaceted framework of safety enhancement initiatives. The Safety Case Management Committee, which has been meeting at the VA Ann Arbor Healthcare System since early 1999, is one such initiative; it is directed at broadening organizational involvement in creating a safer clinical environment. The committee's objective is to address fundamental issues related to patient safety and quality of care. The committee aims to develop thematic approaches to improving major systems triggered by unsafe or risky incidents that demonstrate either iatrogenic harm or risk of harm to patients. COMMITTEE STRUCTURE AND FUNCTIONING: Committee members represent top management, middle management, and front-line employees, but membership is weighted toward those in direct patient care roles. The group also includes a consumer representative. Critical issues are addressed through rigorous case discussion, literature review, and expert consultation.ResultsIn a 3-year period (Feb 1999 through Dec 2001), 85% of the group's 45 recommendations have been implemented. Topics have included reducing medication errors during emergency procedures, enhancing palliative care services, minimizing the risk of missed x-ray findings, optimizing anticoagulation management, reducing the risk of vascular catheter-related infection, and improving pain management.SummaryThe Safety Case Management Committee has successfully addressed actual and potential errors and has implemented strategic safety improvements. The dedicated efforts of highly motivated clinicians who serve on such a committee can augment and enhance risk management advances made through other channels.

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