Preventing Medical and Surgical Preventing Medical and Surgical Errors in the Department of Errors in the Department of Defense Military Health Care Defense Military Health Care

SystemSystem

Colonel Mark F. Torres, MDColonel Mark F. Torres, MDChairman of OphthalmologyChairman of Ophthalmology

Ophthalmology Consultant to the US Ophthalmology Consultant to the US Army Surgeon GeneralArmy Surgeon General

Madigan Army Medical CenterMadigan Army Medical CenterTacoma, WashingtonTacoma, Washington

DisclaimersDisclaimers

► I wear the same clothes every day I wear the same clothes every day (i.e. government employee)!(i.e. government employee)!

► I receive regular paychecks in very I receive regular paychecks in very modest amounts (i.e. no financial modest amounts (i.e. no financial interests)!interests)!

► If the government wanted me to have If the government wanted me to have an opinion, they would have issued an opinion, they would have issued me one (i.e. not official policy)!me one (i.e. not official policy)!

Risk Factors for Patient Safety Risk Factors for Patient Safety in Ophthalmologyin Ophthalmology

►Large patient volumesLarge patient volumes►Large number of short duration Large number of short duration

surgical proceduressurgical procedures►Large amount of prosthetic device Large amount of prosthetic device

usageusage►One-sided surgery – even when One-sided surgery – even when

bilateral!bilateral!

Risk Factors for Patient Safety Risk Factors for Patient Safety in Military Health Care Systemin Military Health Care System

►Hospital-based practice – differs from Hospital-based practice – differs from civilian sectorcivilian sector

►Must work cooperatively across health Must work cooperatively across health professions, specialties, and locationsprofessions, specialties, and locations

►Variable personnel and turnoverVariable personnel and turnover►Personnel in various training programs Personnel in various training programs

and at various stages of trainingand at various stages of training

High Risk EnvironmentHigh Risk Environment

►Wrong patientWrong patient►Wrong siteWrong site►Wrong sideWrong side►Wrong procedureWrong procedure►Wrong personnelWrong personnel►Wrong equipmentWrong equipment

Team STEPPSTeam STEPPS

►Madigan Army Medical Center 2009Madigan Army Medical Center 2009►Department of Surgery, Department of Department of Surgery, Department of

Anesthesia, and Department of Nursing in Anesthesia, and Department of Nursing in operating room environmentoperating room environment

►PremisePremise – freedom of communication acts – freedom of communication acts to counterbalance a risky environmentto counterbalance a risky environment

►GoalGoal – improve patient safety and – improve patient safety and outcomes through improved outcomes through improved communication across the health care communication across the health care teamteam

Salient FeaturesSalient Features

►BriefBrief – prior to surgery, all personnel – prior to surgery, all personnel►Time-OutTime-Out – before any procedure – before any procedure

begins, verify patient, procedure, side, begins, verify patient, procedure, side, sitesite

►Hand-OffHand-Off – transfer patient care – transfer patient care between health care personnel (SBAR between health care personnel (SBAR format)format)

►Out-BriefOut-Brief – identify any miscues on – identify any miscues on previous procedure previous procedure

What Team STEPPS can What Team STEPPS can do !!do !!

►Empower personnelEmpower personnel► Improve communicationImprove communication►Prevent medical and surgical errorsPrevent medical and surgical errors► Improve patient safety and outcomesImprove patient safety and outcomes►Break down old barriers and Break down old barriers and

stereotypesstereotypes►Complement and educate on risk Complement and educate on risk

managementmanagement

What Team STEPPS will not What Team STEPPS will not do !!do !!

►Challenge leadershipChallenge leadership►Create perfectionCreate perfection►Careful to avoid the “no defects – Careful to avoid the “no defects –

zero tolerance” mentalityzero tolerance” mentality►Not designed to be used in a punitive Not designed to be used in a punitive

fashionfashion

Questions / Questions / CommentsComments

Thank You !!Thank You !!