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Preventing Contextual Errors Program

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A “contextual error” occurs when a care plan appears appropriate based on the limited information in the medical record, but is, in fact, inappropriate because it does not address specific life challenges the Veteran is facing that complicate their care. For example, increasing the insulin dose in a patient with uncontrolled diabetes when the underlying problem is that their vision is failing and they can’t read their insulin syringe, or that they have untreated depression and have stopped taking their medications consistently is a contextual error. In the Preventing Contextual Errors (PCE) program, Veterans are invited to carry an encrypted audio recorder into their visit when they check in for their appointment and return it when they leave. The data is uploaded to a secure server and audio-coded by a specialized team in Chicago that also has access to the patient’s medical record. Anonymized reports are sent back to care teams as feedback with examples of contextual errors and appropriately contextualized care. The program has measurably reduced contextual error rates and improved Veteran health care outcomes across multiple VHA ambulatory sites.

This innovation is replicating across multiple facilities as its impact continues to be validated. See more replicating innovations.


8 successful


Diffusion of Excellence, Health Services Research & Development



  • See publication which presents data on over 4000 audio recorded visits. Contextual error rates dropped by 15% over 2 years, and resulted in $25M in preventable hospitalizations. $75 was saved for each $1 invested in the program.

Diffusion tracker

Does not include Clinical Resource Hubs (CRH)


There are no in-progress adoptions for this innovation.

There are no unsuccessful adoptions for this innovation.




The blue line shows the percentage of audio recordings collected by patients and audio coded by the team in Chicago in which an identified challenge faced by the Veteran that was impacting their care (e.g. lack of transportation, loss of a caregiver) was addressed during the encounter. The yellow line shows the percentage of audio recordings in which a clue that a Veteran might be facing such a challenge (a “contextual red flag”) was explored (“probed”) by their physician during the visit. From June of 2017 to December of 2018, providers received regular feedback on their performance. Charts such as this one are generated for every participating site for clinical champions to review at each feedback session.


The Preventing Contextual Errors program offers an unusual opportunity for Veterans to play an essential role in helping improve care for other Veterans at their facility. In fact the program would not be possible if Veterans did not see value in volunteering to audio record their visits. Veterans have a high level of commitment to helping other Veterans. The PCE program produced several different kinds of “thank you” stickers, such as this one, given to Veterans when they returned their audio recorders. These stickers also help advertise the program to other Veterans who may not know about it.


Audio recording becomes less threatening when everyone understands that it serves an exclusively educational purpose, and will not be used to single out or rate any provider’s individual performance. Photos such as this one are included in a brochure about the program, illustrating a primary care physician interacting with a Veteran while data is collected via audio for the PCE program. Veterans who volunteer to record their visit are told they can conceal the recorder, carry it out in the open, or turn it off if they change their mind at any point in time. Most put it in their pocket. Surveys of participating physicians and Veterans indicate that few are distracted or bothered by the audio once they understand its purpose.



An overview of how clinical champions give colleagues feedback using Powerpoint slides we provide, customized for each clinic based on audio coded data, to improve patient care.