The VHA National Center for Patient Safety (NCPS) develops, leads, and oversees activities and programs concerned with improving patient safety throughout the Veterans Health Administration (VHA), which covers 143 Medical Centers and over 1,234 VA Outpatient Sites.  NCPS is a national program office which reports to the Assistant Deputy Under Secretary for Health for Quality, Safety, and Value (10E2/QSV).  The NCPS mission is to prevent inadvertent harm to Veteran patients.  NCPS employs a systems approach that emphasizes prevention as the preferred method to accomplish this goal.  NCPS develops, recommends, and implements VHA policy in the area of patient safety, conducts ad hoc analyses, and provides professional guidance on patient safety concerns, including nationwide education and training and tool/toolkit development.  NCPS improves the safety and quality of care provided to VA beneficiaries by working with VA Central Office Program Offices, Networks, and facilities to reduce medical adverse events and minimize untoward outcomes consequent to medical care.  NCPS also assumes a lead role in planning, implementing, and managing VHA initiatives and programs concerned with patient safety.