SPRING 2009 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

INSIDE: Patient Safety Awareness Week Insert

HEIDI KING RECEIVES NATIONAL PATIENT SAFETY FOUNDATION

CHAIRMAN’S MEDALs. Heidi King, Director, Department of Defense (DoD) Healthcare Team Coordination Program since 2002 and currently Acting Director, DoD

Patient Safety Program received the prestigious National Safety Foundation Chairman’s Medal on May 21, 2009. Presented at a special ceremony during the National Patient Safety Foundation (NPSF) Annual Congress, the medal recognizes emerging leadership in the field of patient safety. It is awarded to an individual who has demonstrated the ability to inspire, to lead and to effectuate measurable posi-tive change and improvement within a culture of respect, openness, learning and team dynamic.

Ms. King’s visionary, motivational leadership and relent-less determination to accelerate widespread improvements in patient safety have resulted in several DoD-led outreach and collaborative efforts, most notably the internationally successful TeamSTEPPS program, developed by the DoD in partnership with the Agency for Healthcare Research and Quality (AHRQ). Pamela Austin Thompson, RN, MSN, FAAN, Chair of the NPSF Board, described the Chairman’s Medal as the “highest award” bestowed by the Foundation. In her presentation remarks, she recognized Ms. King as an “innovator whose work has had a far-reaching impact on the field of patient safety”.

The many DoD leaders and providers who have worked under Ms. King’s leadership as TeamSTEPPS champions, trainers and practitioners readily attest to her inspiration, tenacity and passionate personal commitment. It is with great pride that all involved in the important DoD mission of keeping our patients safe say CONGRATULATIONS to Ms King for her well-deserved national recognition, and THANK YOU to a leader of uncommon vision and skill.

National Award Recognizes Leadership In Patient Safety

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Heidi King, Acting Director, DoD Patient Safety Program, receives National Patient Safety Foundation (NPSF) Chairman’s Medal from NPSF Board Chair Pamela Austin Thompson, RN, MS, FAAN (middle). With them, left to right are former NPSF board chairs Paul Gluck, MD; Carol Ley, MD, MPH; Timothy Flaherty, MD. Photo taken by Event Digital Photography, Inc.

TABLE OF CONTENTS 5 Fall Conference Highlights 6 PSP News 8 TRICARE Patient Safety Month

NATIONAL PATIENT SAFETY FOUNDATION CONGRESS HIGHLIGHTSDoD Providers Attend Congress, Award Presentation Culminates Busy Day

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HEIDI KING ACCEPTS AWARD The NPSF Chairman’s Medal was presented at the Lucian Leape Institute Town Hall Plenary. A panel of nationally acclaimed patient safety leaders witnessed the award ceremony: Paul O’Neill, former Treasury Secretary; Dennis O’Leary MD, Pres. Emeritus, The Joint Commission; Julianne M. Morath, RN, MS, Chief Quality and Safety Officer, Vanderbuilt Medical Center; James A Guest, Pres., Consumers Union; Lucian Leape, MD, Harvard School of Public Health; Janet Corrigan, PhD, MBA, Pres. & CEO, National Quality Forum; Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality; David Lawrence, MD, Kaiser Foundation Health Plan, Inc.; Donald M. Berwich, MD, MPP, Pres & CEO, Institute for Healthcare Improvement. In accepting the Chairman’s Award, Ms. King recognized the many dedicated providers from DoD facilities. She told the NPSF audience:

“This would not be possible without our dedicated team working in the Department of Defense Patient Safety Program and those in the field on the frontlines of care… We are energized by the success stories we hear from our providers in the field on how they are preventing medical errors, stop-ping them before they reach the patient. “We all play a vital role…If you are a care provider, make every patient visit count by empowering your patients to become informed, active participants on their care team. Leaders, renew your commitment to enable our most valuable asset — our people — to provide safe care in a learning environment where they may openly communicate, work together, and learn from their mistakes so that no other patient will be harmed from the same error.”

Heidi King, Acting Director DoD Patient Safety Program, addresses distinguished members of the Lucian Leape Institute and the NPSF audi-ence after receiving the Chairman’s Medal. Photo taken by Event Digital Photography, Inc.

MHS LEADERSHIP CONGRATULATES AWARD RECIPIENT Heidi King, Acting Director, DoD Patient Safety Program, poses at the National Patient Safety Foundation Congress with COL James Black, Senior Medical Director, TMA, and Jack Smith, MD, MMM, Acting Deputy Secretary of Defense for Clinical Policy and Programs. COL Black shared these congratulatory comments:

It is my great pleasure to congratulate Heidi on being awarded the National Patient Safety Foundation Chairman’s medal. She has inspired countless providers, nurses, and other healthcare team members to embrace and execute TeamSTEPPS. The visible results of her efforts and the out-pouring of positive and thankful comments from those in the field is a testament to her extraordinary achievements.

COL James Black, Senior Medical Director, TRI-CARE Management Activity, Heidi King, NPSF Chairman’s Medal recipient, and Jack Smith, MD, Acting Deputy Secretary of Defense for Clinical Policy at the National Patient Safety Foundation Conference.

DOD PROVIDERS ATTEND NPSF CONFERENCE A large contingent of DoD patient safety staff from across the Military Health System attended the Na-tional Patient Safety Foundation Congress. Patient Safety Managers Scott Chitten-den, Yokota AFB and Marcia Vondran Lutz, Mountain Home AFB talked about the Conference and TeamSTEPPS. Scott Chittenden found that patient safety expert Lucian Leape’s comments resonated with his experience: “Dr. Leape said that the two most important things necessary to reform healthcare are teamwork and the resources to implement it. We’ve found at Yokota medical care is at its best when the team is complete”. Vondran Lutz says that providers at Mountain Home AFB find TeamSTEPPS “very valuable”. They have enhanced their experience by adding the DoD HFACS human factors component to their program, which they believe has helped reduce same event errors.

Pictured, left to right: Theresa Clark, Mountain Home AFB, Idaho; Carole Durant, Elmendorf AFB, Alaska; Scott Chittenden, Yokota AFB, Japan; Marcia Vondran Lutz, Mountain Home AFB, Idaho; Suzanne Berrong, Aviano AFB, Italy; Judy Criner, PhD, RN, Joint Commission Readiness Consultant, Tripler AMC, Hawaii.

ne year ago TeamSTEPPS was successfully introduced to the 86th Combat Support Hospital (CSH)

in Baghdad. In late November 2008, with the support of the Patient Safety Program’s Healthcare Team Coordina-tion Program (HCTCP), TeamSTEPPS was expanded to 10th CSH as part of the overall plan to utilize TeamSTEPPS throughout the combat theater. Over 1,000 military medical personnel serv-ing in Iraq are currently TeamSTEPPS trained. Now just one year after it first went to war, TeamSTEPPS is an integral, widespread part of the acute medical care available to our wounded warriors.

Like their counterparts at the 86th CSH, providers from the 10th CSH are enthusiastic in their embrace of Team-STEPPS. The successes they share below are examples of TeamSTEPPS principles at work in the midst of the chaos and challenges of combat. Utiliz-ing varied techniques, the theme is the same –TeamSTEPPS training empowers staff of every level and discipline to act as a seamless unit for the benefit of the patients they share.

SITUATION MONITORING A Lifesaving TeamSTEPPS Lesson

TeamSTEPPS teaches providers to reduce error by continually scanning and assessing what is going on around them, ensuring that changes are quickly caught. Team members monitor each other’s actions and provide a mutual safety net within the team.

Constant situation awareness by team members at the 10th CSH ensures that any rapid and unpredictable deterioration in the status of their patients is readily observed, assessed and treated. In the combat environment this TeamSTEEPS tool has proven to be a particularly criti-cal asset, as so many patients suffer from complex trauma injuries which increase the likelihood of unexpected changes. Providers from the 10th CSH report that all team members feel empowered by TeamSTEPPS to assess potentially life-threatening situations and take appropri-ate action to keep patients safe. With its

shared focus on timely intervention and collective responsibility, this Team-STEPPS tool has allowed team members no matter their rank or specialty to en-gage and react, resulting in good catches and saved lives at the 10th CSH.

HANDOFF and SBAR COMMUNICATION TOOLS What You Don’t Know Can Hurt Your Patient

TeamSTEPPS places a high priority on communication and provides a variety of tools to ensure that patient information is communicated among providers. During transitions of care, the HANDOFF sends critical information along with the patient so that safety is not compromised because significant facts are unknown. While car-ing for a patient, providers are taught to clearly and succinctly share actionable in-formation using the SBAR technique – a description of the Situation, Background, Assessment and Recommendation.

In combat support hospitals like the 10th CSH, host nation patients are frequently treated. In addition to their expected complex medical conditions, these patients represent a diversity of languages and cultures which often pres-ent additional communication challenges. Team members from the 10th CSH report that the TeamSTEPPS Handoff and SBAR tools have been especially useful to them in caring for host nation patients. These techniques have enabled providers to quickly recognize incom-plete reports from the field, perform more systematic patient assessments, and identify patients with critical conditions that warrant higher levels of care. Staff are confident that use of these structured TeamSTEPPS tools has mitigated com-munication difficulties, further prevent-ing patient harm and saving the lives of host nation patients.

THE HUDDLE The Team that Huddles Together Helps Together

TeamSTEPPS empowers each team member to speak up, challenge and lead when appropriate. The HUDDLE, an ad hoc problem solving technique, al-lows team members to reassess, rein-force, or readjust plans as necessary to assure the safety of their patient.

Team members from the 10th CSH re-port that, in the dynamic arena of combat medicine, the huddle is an ideal way to reassess changing patient care conditions and problem solve to provide the most appropriate care. Transporting patients from combat support hospitals to other levels of care is a continuing necessity and an on-going challenge. Transporta-tion plans may need to be changed on the tarmac if a patient’s condition deterio-rates or a medevac helicopter or civilian air ambulance lacks specialized equip-ment. Teams from the 10th CSH rely on the huddle throughout the transportation process. They take a time-out on the spot to redirect or reprioritize transporta-tion plans when this is indicated, assur-ing that patients are provided the safest level of care from the time they arrive at the 10th CSH to the moment they leave.

For over a year now TeamSTEPPS has been utilized in the theater of opera-tions. These successes from the 10th CSH tell a tale of provider dedication and enhanced patient care. They send a clear message that TeamSTEPPS is help-ing to keep our patients in the combat zone safe from additional harm.

TEAMSTEPPS: A COMBAT VETERAN10th Combat Support Hospital Adopts TeamSTEPPS; Shares Successes

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atients in Military Treatment Fa-cilities (MTFs) across the Military Health System (MHS) are assured the

highest level of safety when they undergo laparoscopic surgery. Thanks to a partner-ship between the National Capital Area Medical Simulation Center (NCAMSC) of the Uniformed Services University (USUHS) and the DoD Patient Safety Pro-gram (PSP), the certification program in the Fundamentals of Laparoscopic Surgery (FLS) has been introduced to the MHS.

The DoD efforts, which began in 2005, followed national release of the FLS cur-riculum.

Released in 2004 by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Col-lege of Surgeons (ACS), the FLS educa-tional program consists of a didactic and a manual skills component meant to improve the level of patient safety during laparos-copy. Major E. Matt Ritter, MD, currently Chief of Minimally Invasive Surgery and

Emerging Technologies at USUHS, serves on the SAGES FLS committee.

Building on his committee experience, Major Ritter teamed with Col (ret) Mark W. Bowyer, MD, Surgical Director at NCAM-SC in 2005 and proposed a more ambitious program which combined the FLS study and certification in one training effort. Because FLS certification is a prerequisite for taking the American Board of Surgery qualifying examination, the thirteen DoD MTFs with residency training programs have been the first to receive FLS training. The training model introduced by Drs. Ritter and Bowyer, with the support of the DoD PSP, is premised on the identifica-tion of a surgeon champion at each facility, who attends a train-the-trainer course at USUHS and returns to his or her MTF to conduct the basic FLS training. Drs. Ritter and Bowyer then schedule their one-day training/testing course, which includes a review of key information, a skills practice segment, and administration of the certifi-cation test.

As recognition of the link between im-proved patient safety and FLS certification has increased across the surgical commu-nity, the DoD model has received national attention. Covidien, a laparoscopic device and equipment manufacturer, has provided an educational grant to fund a similar pro-gram to deliver FLS to civilian residency training programs. Many civilian training programs are using the Train the Trainer deployment strategy developed by Drs. Rit-ter and Bowyer and the PSP as their model.

The DoD FLS Patient Safety Program goal that surgeons doing laparoscopic surgery have, as a minimum, FLS certifica-tion has resulted in reports of significant improvement in safety related knowledge among those trained. To date, nearly 200 surgical providers across the MHS have been trained. This joint initiative promises continued success and exemplifies the cre-ativity and dedication the military brings to its mission of keeping patients safe, within its own walls and well beyond.

DOD LEADS IN LAPAROSCOPIC SURGERY TRAINING

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Surgical Residents at MTFs Meet Certification Requirements

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FLS Certification Course, Tripler Army Medical Center (TAMC), March 2009. Maj E Matt Ritter (NCAMSC, USUHS) reviews key information with TAMC OB/GYN residents and attendings.

FLS Certification Course, Tripler Army Medical Center (TAMC), March 2009. CPT Torie Plowden and CPT Saioa Torrealday, TAMC OB/GYN residents practice their FLS skills.

The Veterans Administration (VA) and the University of South Florida sponsored the 10th Annual Patient Fall Education Conference held in Clearwater Florida May 4-8, 2009. For the first time the DoD Patient Safety Program (PSP) was a co-sponsor.

Representatives from all three services attended and DoD participation oc-curred at all levels of the conference. Dr. Geoffrey Rake, Director, DoD Patient Safety Center (PSC), delivered opening remarks. John Courtney, Senior Systems Analyst, Patient Safety Program, managed the PSP booth. National Naval Medical Center exhibited two posters. Conference sessions were presented by Carla Alexis, PT, Walter Reed Army Medical Center, and Erin Lawler, Human Factors Engineer, DoD PSC, and LCDR Diane Hite, NC, National Naval Medical Center.

The Conference focused on the latest research and suggestions for prevent-ing patient falls and reducing fall related injuries. Fall management strategies for various settings were presented, and special break-out sessions examined fall risks unique to particular populations. The Conference emphasized four main topics: categories of falls, components of a credible falls reduction program, populations at risk for greatest harm from falls, and technology to aid falls prevention. Of the numerous tips and strategies presented, highlights included:• Incorporate postural blood pressures in at risk patients for falls.• Avoid using benzodiazepines in the elderly• Use post-fall huddles to develop a team approach to treating falls• Standardize the sitter process—develop training and competencies• Discuss fall risk and interventions during shift changes and patient hand-offs

The 11th Annual Falls Conference will be held on May 3–7, 2010 in Clearwater, Florida. The DoD Patient Safety Program will again be a co-sponsor. Consider sub-mitting posters that showcase your facility’s innovative fall reduction efforts. Plan to attend with members of your fall team. Take advantage of this opportunity to network with other fall champions and learn strategies and evidence-based consider-ations that will challenge you to transform your facility’s fall reduction program.

Presentations and posters will be provided on request. Contact information for presenters: Carla.alexis@us.army.mil; Lawlere@afip.osd.mil. Contact informa-tion for posters: Mary.farley@med.navy.mil.

HIGHLIGHTS: PATIENT FALL REDUCTION CONFERENCEDoD Co-Sponsors 10th Annual Event

Designating a Safe Room for Patients at High Risk for Fall-Related InjuriesLDCR Diane Hite, NC and Erin Lawler, Human Factors Engineer, PSC

LCDR Diane Hite and Erin Lawler pre-sented to a near standing room only audience as they discussed critical design features that can either hinder or support falls prevention in a patient room. The presentation highlighted Evidence Based Design features and research relative to the built environment, as well as technology and ergonomic considerations that can influence the rate and severity of falls events. The duo ended by providing valuable tips to those who work in older environments or spaces that may present hazards for falls. “Make it Obvious” was the key take-away from the session. They recommended that falls teams increase visibility and situational awareness of the hazards, as well as support features, that ex-ist in a patient room with low cost interventions. Orienting patients and families to these hazards and features, and bringing them in as partners to the care process is a critical component.

Special Issues Related to Fall Risks in Traumatic Brain InjuryCarla Alexis, PT, Walter Reed Army Medical Center

Carla Alexis, PT, Traumatic Brain Special-ist, presented the pathophysiology of vestibular dysfunction in Traumatic Brain Injury (TBI) patients. During the presentation, Ms. Alexis stressed that a distorted sense of orientation, which may be acute, intermittent or chronic, may cause TBI patients to feel like the room is spinning or they are walking sideways. Sugges-tions for managing patients suffering from TBI include taking a detailed history and customiz-ing patient specific fall prevention interventions. It is important, when changing the position of a TBI patient, to do so very slowly. Reducing provider bias that reported symptoms reflect PTSD, rather than vestibular dysfunction is an on-going challenge.

DOD CONFERENCE PRESENTATIONS

DoD Falls Conference participants with Conference Program Director. Back row, l to r: ENS Brad Respondek, NC, National NMC; Pamela Copeland, RN, DoD Patient Safety Center; ENS Henry Lang, NC, National NMC; Dr. Geoffrey Rake, Director, DoD Patient Safety Center; 2nd Lt Kala Wehner, NC, Wright-Patterson AFB; Terri Sharpe, RN, Patient Safety Manager, Walter Reed AMC; Loma Moore, RN, Patient Safety Manager, Fort Meade; Rudy Lujan, Patient Safety Manager, Wright-Patterson AFB; Dr. Gail Powell-Cope, James Haley VAMC; Dr. Patri-cia Quigley, Program Director, 10th Annual Conference; front row, l to r: Violet Gordon, RN, National NMC; LCDR Diane Hite, NC, National NMC; Judith Miller, RN, National NMC; ENS Koa Thomas, NC, National NMC; Carla Alexis, PT, Walter Reed AMC; Erin Lawler, MS, DoD Patient Safety Center. Photo Taken By: Andrea M. Spehar.

NEWS FROM THE PATIENT SAFETY CENTERfeedback and Suggestions Based on your Reporting

Pamela Copeland, JD, RN, BSNPatient Safety Analyst

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PATIENT SAFETY PROGRAM INITIATIVESOpportunities for the field

The Patient Safety Program is pleased to share the following updates on system-wide initiatives that resonate across the entire scope of the MHS patient safety efforts.

OL Steven W. Grimes, United States Army, Nurse Corps, has retired from U.S. Army and his position of Direc-

tor, DoD Patient Safety Program (PSP). Director since August 2005, COL Grimes distinguished himself as a communicator, a relationship-builder and a champion for the Patient Safety Program. He worked tirelessly to facilitate coordination and co-operation among the services, and between the Patient Safety Planning and Coordina-tion Committee (PSPCC) leadership and program providers. During his tenure, COL Grimes facilitated the successful de-ployment of three significant program-wide initiatives -- the Patient Safety Culture Sur-vey, a web-based patient safety reporting system (PSR), and increased collaboration with national patient safety organizations.

COL Grimes leaves his position having firmly established the DoD Patient Safety Program as a leader in national patient safety efforts. He forged relationships with the Veterans Administration (VA), the In-stitute for Healthcare Improvement (IHI), and with the Centers for Disease Preven-tion and Control (CDC). Thanks to his

efforts, there is now an ongoing VA-DOD Joint Strategic Plan; the DoD participates in the IHI 5 Million Lives Campaign; and a collaborative relationship exists between the DoD Infection Control Program and the National Healthcare Safety Network (NHSN), the CDC’s web-based tool for infection surveillance, aggregation and analysis.

Within the PSP, COL Grimes leaves a legacy of increased customer satisfaction and communication. His belief that the three Patient Safety Division components – the Patient Safety Center (PSC), the Center for Education and Research in Patient Safety (CERPS), and the Healthcare Team Coordination Program (HCTCP) – should be better coordinated resulted in joint ef-forts that made the entire Program greater than the sum of its parts. In addition to the long-awaited Patient Safety Reporting System, COL Grimes’ efforts have inspired a more user-friendly website, an enhanced patient safety manager course, and the na-tionally recognized TeamSTEPPS program.

Like all exceptional leaders, COL Grimes leaves the Patient Safety Program

stronger for his efforts. This fall the Pro-gram will welcome its new director, LTC Donald Robinson, MD, a trauma surgeon, currently assigned to the Army Trauma Training Center in Miami, Florida. In the interim, Ms Heidi King will be acting Di-rector of the PSP, assisted by Mike Datena the acting Deputy Director.

he Patient Safety Program has de-veloped an action-oriented guide to assist new Patient Safety Managers

(PSMs). The idea for the guide originated from the 2008 Tri-Service Survey on Patient Safety Culture, with the desire to share safety improvement practices under-way throughout the Military Health System (MHS).The Guide includes:• MHS results from the Tri-Service Sur-

vey on Patient Safety• A procedure to take data and create an

action plan for safety improvement

• Patient safety activities and lessons learned from selected MTFs The Guide showcases select Military

Treatment Facilities (MTFs) based on their culture survey scores amongst other fac-tors. The factors include high overall scores on the 2008 survey, score improvements between the 2005/06 and 2008 surveys, Ser-vice branch, facility type (hospital or clinic), and facility size. Based on these criteria, nine facilities were chosen to be interviewed. The contents of the patient safety activities and lessons learned reflect information obtained through those interviews.

The Guide will provide new Patient Safety Managers with ideas, lessons to consider, and a framework to determine which patient safety activities may offer the greatest benefit for their facilities. The new Patient Safety Managers will quickly notice that there are no silver bullets to improv-ing patient safety; rather, it takes leadership commitment, individual persistence, and the ongoing engagement of all staff.

To obtain the Improvement Guide, visit the Patient Safety Program website: http://dodpatientsafety.usuhs.mil.

PATIENT SAFETY PROGRAM LEADERSHIP TRANSITIONS

DOD PATIENT SAFETY IMPROVEMENT GUIDE

COL Steven Grimes Retires; Successor is LTC Donald Robinson, MD

Ideas for New PSMs Now Available!

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COL Steven Grimes, Director DoD PSP August 2005 to April 2009.

PATIENT SAFETY PROGRAM INITIATIVESOpportunities for the field

The Patient Safety Program is pleased to share the following updates on system-wide initiatives that resonate across the entire scope of the MHS patient safety efforts.

he Patient Safety Reporting (PSR) sys-tem is a Tri-Service management sys-tem that will automate patient safety

event reporting and help identify areas for patient safety improvement in the MHS. PSR will consolidate both medication and non-medication event reporting into one system and will enable the MHS to capture, track, trend healthcare events, aggregate de-identified information for reporting and standardize reporting across the enterprise. PSR provides a systematic methodology to reduce the frequency and severity of medical events by incorporating comprehensive anal-ysis tools to identify enterprise-wide safety improvement strategies.

PSR has completed configuration for the initial nine test sites and began devel-opmental test and evaluation (DT&E) on

May 18, 2009. DT&E is the first step in system fielding and consists of an evalua-tion and report to the Program Manager on how well the system functions against requirements. After DT&E PSR will proceed into System Qualification Testing (SQT) which is the first time the func-tional user community gets to test the system. Following successful SQT the system is given the green light to proceed with limited deployment. The sites for this initial deployment and the next round of testing are:Army • Madigan Army Medical Center• Martin Army Community Hospital• Kimbrough Ambulatory Care CenterNavy• National Naval Medical Center

• Naval Hospital Pensacola• Naval Hospital Camp LejeuneAir Force• Malcolm Grow USAF Medical Center• Wilford Hall USAF Medical Center• Davis-Monthan AFB Clinic

In January 2010, live users will get their first chance to evaluate PSR. Following a 30-60 day user familiarity period, Opera-tional Test and Evaluation (OT&E) will be-gin. OT&E will be run by an independent testing agency and will evaluate the system for suitability, survivability and sustainabil-ity based on observations and interviews with staff in the live environment. Assum-ing successful OT&E, full implementation across the MHS direct care system would begin in July 2010.

new team training tool on Rapid Response Systems (RRS)recently has been released as a collaborative effort

by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD). This new training module, designed for use by hospital teams, complements the Teams Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPST) module, published in 2006.

Research suggests that after implement-ing a Rapid Response System, hospitals experience a decrease in the number of cardiac arrests, deaths from cardiac arrest, the number of days in the intensive care unit and the hospital overall post arrest, and inpatient death rates. This new module provides an overview of the Rapid Re-sponse System and the role of the Rapid Response Team, which is composed of clinicians who bring critical care expertise to patients requiring immediate treatment while under hospital care.

This evidence-based module is available in CD format. Utilizing a set of vignettes demonstrating rapid response system prob-lems and solutions and curriculum slides which can be customized to meet an insti-tution’s unique needs, the module provides insight into the core concepts of teamwork as they are applied to the Rapid Response system. The module is accom-panied by an Instructor Guide. The Guide includes a complete course planning package (suggested lesson plans and resources, and tools for monitor-ing, evaluation and ongoing coaching), as well as a complete set of materials

for training instructors.Free copies of the new RRS module CD

are available at: http://teamstepps.ahrq.gov/abouttoolsmaterials.htm or by call-ing AHRQ’s publication clearinghouse at 800-358-9295.

PATIENT SAFETY REPORTING SYSTEM UPDATE

HOSPITAL RAPID RESPONSE SYSTEMS TRAINING TOOL AVAILABLE

Developmental Testing and Evaluation to Begin

AHRQ and DoD Release New Team Training Module

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SPRING 2009 PatIeNt Safety 7Sample slide from Rapid Response System Module.

MAY: TRICARE PATIENT SAFETY MONTH

s part of its focus during May Patient Safety Month, TRI-CARE encouraged beneficiaries to take an active role in their medical care. The following article, contributed by

Patricia Opong-Brown, Public Affairs Division, TRICARE Com-munications and Customer Service Directorate, explains the DoD TEAM-UP Initiative.A Checklist to Help TRICARE Beneficiaries Be Active Members of their Health Care

Today’s patients can and should take an active role in their medical care. During Patient Safety Month, TRICARE especially wants to encourage beneficiaries to do just that. Patients who make an extra effort to communicate with their health care providers, as part of a team approach, can help build trust and improve their provider-patient relationship.

The TEAM UP program is a Department of Defense (DoD) initiative implemented at Madigan Army Medical Center at Fort Lewis, Wash. It encourages use of a checklist, which is available on the TRICARE patient safety program Web site at http://dodpa-tientsafety.usuhs.mil/teamup. “TEAM UP allows beneficiaries to be more active in promoting safe, quality healthcare”, says Heidi King, Acting Director, DoD Patient Safety Program.

The following TEAM UP checklist will help beneficiaries com-municate more effectively with their primary care managers (PCMs):Team Together • Choose to be an active member of your care team.• Invite persons close to you to be members.• Follow the TEAM UP steps.Educate Yourself• Ask members of your care team to repeat their names and

explain their roles.• Know the plan for treatment and your role in it.• Write it all down.Ask Questions• Situation: What is gong on with my care now?• Background: What information do I need to understand the

situation?• Assessment: What are the options to consider?• Recommendations: What is gong to be done?Manage your Medications• Provide a list of medications (prescriptions, over-the-counter

and herbal remedies).• Write down what medications are prescribed and why.• Read each medication label carefully• Alert the care team if a medication label does not match what

was prescribed.Understand Changes in the Game Plan• Listen to how the game plan has changed.• Ask Questions.• Repeat the new game plan back to the care team.Provide your Perspective• Share all your feelings with your care team• Raise concerns immediately.• Repeat the concern and include why it makes you uncomfort-

able and how it may be a safety issue.For additional information about playing a more active role in

personal health care, beneficiaries should talk with their PCM or visit the Patient Safety Program website at: http://dodpatientsafety. usuhs.mil/teamup.

“It is important when something doesn’t seem right that you speak up immediately to the nurse or doctor who’s taking care of you”

COL John Kugler, Director, TRICARE Office of the Chief Medical Officer, practicing physician at DeWitt Health Care Network, Fort Belvoir, Va

ABeneficiaries Encouraged to Actively Participate in Treatment

DoD Patient Safety Program Office of the Assistant Secretary of Defense (Health Affairs)TRICARE Management Activity Skyline 5, Suite 810, 5111 Leesburg Pike Falls Church, Virginia 22041 703-681-0064

Forward comments and suggestions to:

DoD Patient Safety Center Armed Forces Institute of Pathology 1335 East West Highway, Suite 6-100 Silver Spring, Maryland 20910 Phone: 301-295-7242 Toll free: 1-800-863-3263 DSN: 295-7242 • Fax: 301-295-7217 E-Mail: patientsafety@afip.osd.mil Website: http://dodpatientsafety.usuhs.mil E-Mail to editor: poetgen@aol.com

ACTING DIVISION DIRECTOR, PATIENT SAFETY PROGRAM Ms. Heidi King

DIRECTOR, PATIENT SAFETY CENTER Geoffrey Rake, MD

ACTING DIRECTOR, CENTER FOR EDUCA-TION AND RESEARCH IN PATIENT SAFETY Howard Steed, PhD

DIRECTOR, HEALTHCARE TEAM COORDINATION PROGRAM Ms. Heidi King

SERVICE REPRESENTATIVES ARMY LTC Anthony Bohlin

NAVY Ms. Carmen Birk

AIR FORCE Lt Col Anne Coyne

PATIENT SAFETY PROGRAM NEWSLETTER EDITOR Phyllis M. Oetgen, JD, MSW

PATIENT SAFETY PROGRAM NEWSLETTER

Published quarterly by the Department of Defense (DoD) Patient Safety Center to highlight the progress of the DoD Patient Safety Program.

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TEAM UP Brochure used as part of the TEAM UP program