,i  #aaeth ,,congress  #ast ,session    
,h4 ,r4 #cgeb  ,,in ,,the ,,house ,,of  
,,representatives  ,september #ab1      
#bjag,mr4 ,norcross 7for himself and    
,mr4 ,costello of ,pennsylvania7        
introduced the following bill2 which was
 referred to the ,committee on          
,veterans' ,affairs  ,a ,,bill  ,to     
direct the ,secretary of ,veterans      
,affairs to develop and implement plans 
to improve the safety of medical        
facilities of the ,department of        
,veterans ,affairs1 and for other       
purposes4  #a4 ,short title ,this ,act  
may be cited as the ,policies to        
,address ,tragic ,injuries ,enabled by  
,never events ,thoroughly ,act or the   
,,patient ,act4  #b4 ,findings ,congress
 finds the following3  7#a7 ,never      
events continue to occur in the health  
care system of the ,department of       
,veterans ,affairs and remain a growing 
source of patient morbidity4  7#b7      
,despite their importance1 never events 
seem to persist as an unsettled issue   

across the ,nation4  7#c7 ,in #bjaf1 a  
national survey announced that ,one in  
,five ,u4,s4 ,hospitals ,fail to ,adopt 
,crucial ,never ,events ,policies44     
7#d7 ,the ,department lacks a mandated  
reporting system for never events that  
would help quantify this problem4  7#e7 
,never events1 such as operating room   
fires1 including those caused by unsafe 
laser fiber practices1 pose serious     
risks1 such as injuries or burns that   
can be severe and permanent1 to both    
patients and health care professionals4 
7#f7 ,the ,department does not currently
 have a comprehensive operating room    
fire safety policy in place to improve  
operating room safety4  #c4 ,improvement
 of safety at medical facilities of the 
,department of ,veterans ,affairs  7a7  
,plans ,the ,secretary of ,veterans     
,affairs1 acting through the ,veterans  
,health ,administration1 the ,national  
,surgery ,office1 and the ,national     
,center for ,patient ,safety1 shall     
develop and implement the following3    

7#a7 ,a comprehensive1 system-wide plan 
to decrease never events that           
incorporates technological tools4  7#b7 
,a comprehensive operating room fire    
safety plan that requires--  7,a7 the   
reporting of operating room fires2  7,b7
 the inclusion of the directives        
outlined in the #bjaa fire safety alert 
of the ,food and ,drug ,administration  
to mitigate risks relating to fires2 and
  7,c7 the carrying out of a pilot      
project that tests and validates new    
operating room fire safety technology at
 multiple medical facilities of the     
,veterans ,health ,administration4  7b7 
,report ,not later than #ij days after  
the date of the enactment of this ,act1 
the ,secretary of ,veterans ,affairs    
shall submit to ,congress a report      
containing the plans developed under    
subsection 7a74  #d4 ,never event       
defined ,in this ,act1 the term never   
event means an event involving the      
delivery of 7or failure to deliver7     
hospital care or medical services       

furnished at a medical facility of the  
,department of ,veterans ,affairs in    
which there is an error in the care or  
services that is clearly identifiable1  
usually preventable1 and serious in     
consequences to patients1 and that      
indicates a deficiency in the safety and
 process controls of the care or        
services furnished with respect to the  
physician or medical facility involved4 
,such term includes operating room      
fires4