The Veterans Health Administration is proud of its extensive efforts to enhance staff and patient safety. The following series of articles highlights some of the innovations in this area. Readers will learn about advances in creating a culture of safety and examples of best practices for reporting adverse events. The Veterans Health Administration is well known for implementation of a system-wide computerized patient record system and bar code medication administration system. Both of these advances have proven to support safety initiatives. This series includes a description of challenges faced in supporting the nurses' role in tracking adverse drug events through the computerized patient record system and its interface with the bar code medication administration system.

Efforts to create a culture of safety have come into sharp focus for Veterans Health Administration. Reporting errors and tracking trends from root-cause analyses have been the basis for safety improvements. The Veterans Health Administration has gone one step further to ensure a culture of safety through the implementation of systems for reporting and analyzing "close calls" or "near misses." Creating a safe environment comes at a cost; the astute nurse executive and finance officer will gain a better understanding of the business case for this investment after reading about the Veterans Health Administration analysis of these efforts.