Objective: To assess variation in safety climate across VA hospitals nationally.

Study Setting: Data were collected from employees at 30 VA hospitals over a 6-month period using the Patient Safety Climate in Healthcare Organizations survey.

Study Design: We sampled 100 percent of senior managers and physicians and a random 10 percent of other employees. At 10 randomly selected hospitals, we sampled an additional 100 percent of employees working in units with intrinsically higher hazards (high-hazard units [HHUs]).

Data Collection: Data were collected using an anonymous survey design.

Principal Findings: We received 4,547 responses (49 percent response rate). The percent problematic response-lower percent reflecting higher levels of patient safety climate-ranged from 12.0-23.7 percent across hospitals (mean=17.5 percent). Differences in safety climate emerged by management level, clinician status, and workgroup. Supervisors and front-line staff reported lower levels of safety climate than senior managers; clinician responses reflected lower levels of safety climate than those of nonclinicians; and responses of employees in HHUs reflected lower levels of safety climate than those of workers in other areas.

Conclusions: This is the first systematic study of patient safety climate in VA hospitals. Findings indicate an overall positive safety climate across the VA, but there is room for improvement.

BACKGROUND: The availability of human papillomavirus (HPV) DNA testing and vaccination against HPV types 16 and 18 (HPV-16,18) motivates questions about the cost-effectiveness of cervical cancer prevention in the United States for unvaccinated older women and for girls eligible for vaccination. METHODS: An empirically calibrated model was used to assess the quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (2004 US dollars per QALY) of screening, vaccination of preadolescent girls, and vaccination combined with screening. Screening varied by initiation age (18, 21, or 25 years), interval (every 1, 2, 3, or 5 years), and test (HPV DNA testing of cervical specimens or cytologic evaluation of cervical cells with a Pap test). Testing strategies included: 1) cytology followed by HPV DNA testing for equivocal cytologic results (cytology with HPV test triage); 2) HPV DNA testing followed by cytology for positive HPV DNA results (HPV test with cytology triage); and 3) combined HPV DNA testing and cytology. Strategies were permitted to switch once at age 25, 30, or 35 years. RESULTS: For unvaccinated women, triennial cytology with HPV test triage, beginning by age 21 years and switching to HPV testing with cytology triage at age 30 years, cost $78,000 per QALY compared with the next best strategy. For girls vaccinated before age 12 years, this same strategy, beginning at age 25 years and switching at age 35 years, cost $41,000 per QALY with screening every 5 years and $188,000 per QALY screening triennially, each compared with the next best strategy. These strategies were more effective and cost-effective than screening women of all ages with cytology alone or cytology with HPV triage annually or biennially. CONCLUSIONS: For both vaccinated and unvaccinated women, age-based screening by use of HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations.

When asked who pays for health care in the United States, the usual answer is "employers, government, and individuals." Most Americans believe that employers pay the bulk of workers' premiums and that governments pay for Medicare, Medicaid, the State Children'sHealth Insurance Program (SCHIP), and other programs.

However, this is incorrect. Employers do not bear the cost of employment-based insurance; workers and households pay for health insurance through lower wages and higher prices. Moreover, government has no source of funds other than taxes or borrowing to pay for health care.

Failure to understand that individuals and households actually foot the entire health care bill perpetuates the idea that people can get great health benefits paid for by someone else. It leads to perverse and counterproductive ideas regarding health care reform.

Context: Studies of prostitution have focused largely on individuals involved in the commercial sex trade, with an emphasis on understanding the public health effect of this behavior. However, a broader understanding of how prostitution affects mental and physical health is needed. In particular, the study of prostitution among individuals in substance use treatment would improve efforts to provide comprehensive treatment. Objectives: To document the prevalence of prostitution among women and men entering substance use treatment, and to test the association between prostitution, physical and mental health, and health care utilization while adjusting for reported history of childhood sexual abuse, a known correlate of prostitution and poor health outcomes.

Design, Setting, and Participants: Cross-sectional, secondary data analysis of 1606 women and 3001 men entering substance use treatment in the United States who completed a semistructured intake interview as part of a larger study. Main Outcome

Measures: Self-reported physical health (respiratory, circulatory, neurological, and internal organ conditions, bloodborne infections) and mental health (depression, anxiety, psychotic symptoms, and suicidal behavior), and use of emergency department, clinic, hospital, or inpatient mental health services within the past year.

Results: Many participants reported prostitution in their lifetime (50.8% of women and 18.5% of men) and in the past year (41.4% of women and 11.2% of men). Prostitution was associated with increased risk for bloodborne viral infections, sexually transmitted diseases, and mental health symptoms. Prostitution was associated with use of emergency care in women and use of inpatient mental health services for men.

Conclusions: Prostitution was common among a sample of individuals entering substance use treatment in the United States and was associated with higher risk of physical and mental health problems. Increased efforts toward understanding prostitution among patients in substance use treatment are warranted. Screening for prostitution in substance use treatment could allow for more comprehensive care to this population.

Patient safety has been a priority in health care since Hippocrates admonished physicians to "first do no harm." Even so, the Institute of Medicine found in 2000 that approximately 98 000 patients die from preventable medical errors each year. Recent US Centers for Disease Control and Prevention estimates project that 270 individuals die each day from hospital-acquired infections. Despite substantial efforts and investments, widespread and substantial improvement is not evident.

The problem is not in knowing what to do. Techniques, tools, and some best practices are available, and many health care organizations are making efforts to apply them. The importance of creating a "culture of safety" has also been noted. This involves continuous vigilance or mindfulness, learning, and accountability. A greater emphasis on safety over productivity and on teamwork over individual autonomy, increased standardization and simplification, and the implementation of an environment in which personnel are encouraged and feel comfortable to report errors and mistakes are needed.

Although creating a culture of safety is important, creating a culture of systems is a more fundamental challenge. In this Commentary, the term systems means systems of care that occur both within and across organizations. For example, in studies involving causes of adverse events in cardiac surgery, more than two-thirds were classified as nontechnical or systems-oriented issues including delays and missing equipment, and more of these problems occurred in cases with adverse outcomes than in successful cases. The greatest barrier to patient safety and safety culture is the inherent fragmentation of the US system of care. Safety will improve when the underlying system of care improves.

As promised during his campaign, and under pressure from many quarters, President-elect Barack Obama may seek badly needed changes in the way the United States finances and delivers health care. Responding to public interest and perceived need, several previous presidents have attempted to enact some kind of national health insurance: Harry Truman in the 1940s, Richard Nixon in the 1970s, and most recently Bill Clinton in the 1990s. These attempts went nowhere. In pursuing comprehensive health care reform, President-elect Obama should be aware of four major reasons why, in the past, we heard so much talk and saw so little action.