The Military Healthcare System hasembraced one of the most excitingchallenges available to improve

patient safety. It has formally joined theInstitute for Healthcare Improvement(IHI) 5 Million Lives Campaign. Each Mil-itary Treatment Facility (MTF) across thethree services is a full participant in thisnation-wide data-sharing initiative.

The 5 Million Lives Campaign builds onthe successful 100,000 Lives Campaign, inwhich 3,100 participating hospitalsreduced inpatient deaths by an estimated122,000 in eighteen months. While contin-uing to fight preventable deaths, partici-pants are now being called to expand theirfocus to protecting patients from medical-ly-induced harm. IHI has targeted twelveproven interventions which US hospitalsare being asked to adopt to save lives andreduce patient injuries (see blue box).

The Department of Defense Patient SafetyProgram (DoD PSP) is coordinating the par-ticipation of its MTFs through the directionof TRICARE Quality Forum, Quality andPSP Service Representatives. They are work-ing closely with Patient Safety Managers,facility leaders and providers as each Serviceand MTF begins to implement its IHI part-nership. While the Services vary in theirstrategies, there is uniform agreementamong them that MTF staff have enthusias-

tically embraced this IHI challenge.Response has been extraordinarily strong,creative and widespread. The followingexamples from each Service provide a

glimpse of the spirit and commitment DoDproviders are bringing to this dramatic,demanding challenge to further improvepatient safety.

FALL 2007 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

INSIDE: SERVICES OUTLINE PLANS FOR IHI COLLABORATION

FALL 2007

5 PSC: Suicide Prevention

DOD FACILITIES JOIN IHI 5 MILLION LIVES CAMPAIGN

Services Share Enthusiasm and Dedication to Improving Patient Safety

6 Army Dental Patient Safety 7 Microsystems Successes

5 Million Lives Campaign Interventions

…from the 100,000 Lives Campaign•Deploy Rapid Response Teams ...at first sign of patient decline•Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction•Prevent Adverse Drug Events (ADEs) ...by implementing medication

reconciliation•Prevent Central Line Infections ...by implementing a series of inter-

dependent, scientifically grounded steps•Prevent Surgical Site Infections ...by reliably delivering the correct

perioperative antibiotics...•Prevent Ventilator-Associated Pneumonia ...by implementing a series

of interdependent, scientifically grounded steps

…new interventions targeted at harm•Prevent Harm from High-Alert Medications ...starting with a focus on

anticoagulants, sedatives, narcotics, and insulin•Reduce Surgical Complications•Prevent Pressure ulcers•Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection•Deliver Reliable, Evidence-Based Care for Congestive Heart Failure•Get Boards on Board

2 FALL 2007 PATIENT SAFETY

Air Force Establishes Rapid Response Teams

The Air Force has chosen, as its initial IHIcollaborative, to adopt a uniform interven-tion across its sixteen in-patient MTFs. Allfacilities are in the process of deployingRapid Response Teams (RRT). PSP Manager,Lt Col Kathryn Robinson, describes a greatdeal of enthusiasm, despite special chal-lenges for those facilities without ICUs. Shecoordinates biweekly teleconferences amongstaff and IHI consultants to facilitate theteams’ successful implementation. ScottChittenden, RN, MA, CEN, PSP Manager,374th Medical Group (MDG), Yokota AirBase and Shelley Drake, BSN, MS, PSP Man-ager, 99th MDG, Nellis Air Force Base sharetheir efforts to date:

374 Medical Group, Yokota Air BaseThe 374th MDG, Yokota began its imple-mentation planning by forming a “ChangeTeam” — a champion physician, a memberfrom the executive committee, an active dutyregistered nurse, and the patient safety pro-gram manager — to lead this project.

The Change Team assessed the current climateand welcomed discussion about forming theRRT. Physicians from the internal medicine

clinic, pediatrics, and family practice providedinput on developing criteria to be used by thenurses to initiate a call to a rapid responder.The criteria will be used for adult and pedi-atric patients admitted to the Family CareUnit. The project inspired the obstetrical med-ical director to develop an Obstetrical Emer-gency Response Team (OBERT). This projectwill be under the direction of the OB MedicalDirector with assistance from the Patient Safe-ty Program Manager.

The hospital has a 24 hour, seven day a weekUrgent Care, staffed by one RN, three med-ical technicians, and one family practicephysician. The Change Team developed arobust RRT responder call roster by incorpo-rating the in-house anesthesiologists duringday hours and the Urgent Care doctor in theevening and early morning. RN and medicaltechnicians are the second responders andare called by the RRT physician when indi-cated. The Family Care Unit nurses andattending physician are always incorporatedin the team, and the attending is always noti-fied when an RRT call is made.

99 Medical Group, Nellis Air Force BaseThe initiatives of IHI’s 5 Million LivesCampaign are familiar to most clinicians atthe Mike O’Callaghan Federal Hospital,home of the 99 MDG at Nellis AFB in LasVegas, Nevada. Multidisciplinary teamscomprised of staff from the Air Force andour VA joint venture partners started

implementing IHI bundles in the ICU aslong as two years ago. Membership in IHIgives their work greater facility-wide visi-bility and importance.

The time and experience-tested resources ofIHI, free on-line, were readily available, use-ful guides as we began to implement the 2008National Patient Safety Goal of the RapidResponse Team (RRT). We easily modified anIHI brochure to fit our facility. The brochureand an introduction to the 5 Million LivesCampaign are included in the patient safetyportion of our new employee orientation.

The collegial bi-weekly teleconferenceshosted by Lt Col Kathryn Robinson, AirForce Patient Safety Program Manager andIHI contact are extremely helpful. Theyallow Nellis to share experiences andprogress with other MTFs with ICUs. As theonly Air Combat Command facility of oursize and complexity, working through theprocess with our peers is energizing.

A physician and nurse champion, chosen fortheir enthusiasm and dedication to qualityimprovement, will attend the December2007 IHI National Conference in Orlando in

5 MILLION LIVESCAMPAIGNContinued from Page 1

Maj James Pollock Nellis AFB physicianchampion for IHI initiative will attend theIHI National Conference in Orlando, FL inearly December, 2007 with ICU nurseCapt Savneet Gill, a fellow RRT member.Maj Pollock, a family practice physician is”...honored to be selected and excited tolearn more about IHI and be an activemember of the IHI Team.”

Pictured around the mannequin during RRT/Code Blue training are 374 MDG staffmembers TSgt Juan Cortez (FP/UC 4N), A1C William Buell (FM, 4N), A1C Crystal Lun-dahl (4N, Derm).

PATIENT SAFETY FALL 2007 3

addition to joining the IHI team.With the dedicated cooperation of our VAcounterparts, the Rapid Response Team pol-icy is written; team, staff, and patient educa-tion materials are prepared; and evaluationforms are ready for use. Our “go-live” date ison target for February 2008.

Army Working Groups Develop Policy from End-User Perspective

The Army Medical Department (AMEDD) iscurrently developing policies related to fourIHI interventions — prevention of Ventilator-Associated Pneumonia, Central Line Infec-tions, and Harm from High Alert Medica-tions, as well as deployment of RapidResponse Teams. Employing a unique, andhighly successful, approach AMEDD is utiliz-ing end-user working groups to draft the cor-porate policies that will guide their IHIinvolvement. The groups cross disciplines,with providers, nurses, respiratory therapistsand patient safety managers represented fromamong the various Army facilities. AMEDDPatient Safety Representative LTC RobertDurkee describes the benefits of the workinggroups as numerous. Not only do the groupsbring together a wide range of talent and sub-ject-matter expertise, they nurture policychampions with deep investment and enthu-siasm, and great credibility among staff. An

unexpected, transformational by-product ofthe working groups has been the dialoguethey have created between policy and practice.

The Army’s system-wide experience with itsVentilator-Associated Pneumonia policy illus-trates the synergies that come from suchhands-on policy development. Based on theinput the working group brought to policydiscussions, and supported by the enthusiasmand creativity of staff implementation, Army

users identified oral care as an additionalcomponent of preventing ventilator-associat-ed pneumonias. AMEDD has added oral careas a bundle component throughout its MTFs,responding to IHI’s suggestion that all partic-ipants in the 5 Million Lives Campaign addtheir own changes in care to reduce mortalityand other forms of harm. In addition, as anactive participant in the Campaign, AMEDDhas shared its ideas and progress with IHI,who uses such lesson learned to refine bestpractices for all participants.

Brooke Army Medical Center — Extraordinary Leadership

Yields Impressive OutcomeWork currently underway at Brooke ArmyMedical Center (BAMC) highlights the suc-cessful adoption of the IHI recommenda-tions within one facility. The InfectionControl Team at BAMC, under the leader-ship of Dr (MAJ) Chris Humphries, spear-headed implementation of the Ventilator-Associated Pneumonia bundle last year.Thanks to the team's leadership and theextraordinary cooperation among physi-cians and nursing staff, BAMC has experi-enced zero pneumonias associated withventilators in one of its ICUs. The team isnow meeting to formally adopt the IHICentral Line bundle. This effort enjoysstrong Command support. It is eagerlyanticipated and is expected to decreaseinfections among BAMC patients.

Tripler Army Medical Center — Leader in Rapid Response System

The development of the Rapid ResponseSystem at Tripler Army Medical Center

Guest Speaker Dr. Terry P. Clemmer, IHI Consultant, answers questions from members ofthe Ventilator-Associated Pneumonia/Central Line Infections working group in September.

COL Carolyn Tiffany, Deputy Chief, MEDCOM Quality Management Division speaks tothe Ventilator-Associated Pneumonia/Central Line Infections working group.

(TAMC) provides an example of theimpact the IHI interventions can create asthey spread outward from individual facili-ties to the wider AMEDD system. Dr. EricCrawley, Chief of Critical Care at TAMC,described the first TAMC RRT (deployedin November, 2006) as a force for positivechange in the inpatient venues, leading to asafer and more collaborative environment.(See Patient Safety Newsletter, Spring2006) Since then TAMC has developed apediatric RRT, and is deepening its RRTexpertise by examining the effects of theRRT on ICU outcomes. Tripler staff willco-facilitate the next Rapid Response Sys-tem Working Group for AMEDD, sharingtheir many years of successful RRT experi-ence to the benefit of patients across theArmy system.

Navy Finds Both Challenge and Affirmation in IHI Collaboration

By joining the IHI 5 Million Lives Cam-paign, the Navy Command is affirmingefforts already underway at many of itsmedical treatment facilities. The currentNavy policy directs the implementation offour IHI bundles — Ventilator-AssociatedPnemonia and Central Line Infections forfacilities with intensive care units (ICUs);Prevention of Adverse Drug Events andHarm from High Alert Medications forothers. The policy also allows Commandsto select and report on additional bundleswith which they may already be engaged.All bedded facilities within the Navy arebeing registered with IHI. They will beginsharing data as soon as the dedicated web-sites are up and running. With implemen-tation of this collaboration, facilitiesacross the system are receiving a strongsignal from the top that the Navy experi-ences related to these interventions willnow become part of the national effort tocreate benchmarks and measurements tosupport best practices and lessons learned.

National Naval Medical Center, BethesdaBased on its history with IHI, dating backto the beginning of the 100,000 Lives Cam-paign in 2005, the National Naval MedicalCenter(NNMC), Bethesda can attest to thebenefits of engaging in this extended effortto save 5 million lives. CDR James Dunne,then Medical Director of the Intensive

Care Unit, and CDR Patrice Bibeau, thenAssociate Director of Cardiovascular andCritical Care, began a voluntary, limitedparticipation in the early IHI efforts toprevent Central Line Infections and Venti-lator-Associated Pneumonia. They formeda multi-disciplinary core team to incorpo-rate the recommended care componentsinto the critical care practice at Bethesda.Even on a limited basis, they have foundtheir IHI collaboration a beneficial assistin beginning their practices to includeimprovements recommended by IHI suchas on-site debriefings and shared resultswith ICU staff.

Barbara Cilento, Clinical Nurse Specialistfor the NNMC ICU reports that as theNavy begins its full participation in theIHI campaign, success in decreasing bothventilator-associated pneumonias and cen-tral line infections has been significant.Going forward she envisions a unique con-tribution to the IHI collaboration fromDoD providers at NNMC and other MTFs— customizing IHI recommendations toaddress the needs of the war-wounded, forwhom infection control potentially pres-ents new challenges.

Naval Medical Center, San DiegoThe official Navy policy to join IHI hasbeen well-received in other facilities.CAPT John Parrish, Director of the Med-ical Intensive Care Unit (ICU) at the NavalMedical Center San Diego (NMCSD)reports that most staff are aware of the IHI5 Million Lives Campaign and are pleasedto become part of such a positive nationalinitiative. Rapid Response Teams (RRT),Ventilator-Associated Pneumonia andCentral Line Infections have been thefocus of significant attention at NMCSDover the last two years, well prior to thecurrent IHI policy. Internal data on theefficacy of RRTs has been so compellingthat the use of the RRT has expandedthroughout the hospital.

CAPT Parrish believes that the official deci-sion to join the 5 Million Lives Campaign,with its data-sharing mandate, will elevateexisting efforts across the Military HealthSystem. The transparent reporting requiredby IHI provides a national standard for bestpractices and lessons learned. Being a partof this national dialogue presents a chal-lenge to continually measure and improve,while providing affirmation and encourage-

ment for the on-going efforts of Navyproviders as they continue their focus onhigh-impact interventions.

IHI Conference — December, 2007 —Inspiration for Continued Success

The Institute for Healthcare Improvement19th Annual Forum on Quality Improve-ment in Health Care will be held Decem-ber 9 through 12 in Orlando, Florida.Representatives of the Department ofDefense Patient Safety Program will be inattendance.

Aptly themed “The Energy of Many”, thenational forum draws nearly 6,000 healthcare professionals from around the world.A Patient Safety track is planned withnumerous workshops related to the inter-ventions of the 5 Million Lives Campaign.Sharing of lessons learned and dialogueamong the many attendees is meant toenergize the already impressive work of theCampaign. DoD PSP attendees are proudto bring Service successes to this world-wide conversation.

As Army, Navy and Air Force participationin the 5 Million Lives Campaign continuesand expands, the catch-phrases of the 2007IHI Annual Forum offer inspiration andencouragement. Drawing on the “Energyof Many” theme, attendees are urged to“Be A Spark”, and are reminded that “Ifyou have enough sparks, you can start afire”. The impressive work already accom-plished by the DoD facilities clearly is butthe beginning of a firestorm of high-impact patient safety initiatives across theMilitary Health System.

4 FALL 2007 PATIENT SAFETY

5 MILLION LIVESCAMPAIGNContinued from Page 3

Approximately 10.8 per 100,000 deaths inthe United States result from suicide(National Center for Health Statistics2007). In 2007 the Joint Commission prom-ulgated National Patient Safety Goal #15requiring organizations to identify safetyrisks inherent in patient populations afterfinding that patient suicide was the mostfrequently reported sentinel event between1995 and 2005.

Environmental safety as defined in health-care encompasses both the physical envi-ronment and the way patients are cared forby staff. Increasingly, patients at risk forsuicide are located in environments outsidethe closed behavioral health unit. Approxi-mately 1,500 suicides take place in inpa-tient hospital units in the United Stateseach year (Busch 2003). While there are aplethora of means by which patientsattempt or commit suicide (ingestions,weapons), the majority occur from hangingor jumping. Suicidal risk patients impose aresponsibility on the healthcare team toprovide the safest overall physical environ-ment. Thoughtful patient care planningand diligence in promoting a safe andsecure environment are the best strategiesfor saving a life.

Assess the Environment Conduct routine multidisciplinary pro-active environmental safety rounds. Whetherthe location is a behavioral health unit, ED,ward or ICU, staff must stand in the shoes ofa suicidal patient and consider the manyitems that may be used to commit suicide,particularly:Hanging risks — interior doors, privacy cur-tain support structures, grab bars, plumbingfixtures, sink drains and bed frames can beused as attachment points. To address:• shorten bathroom doors; modify their

hinges• use curtains, accordion doors or pocket

doors and breakaway rods• cover plumbing fixtures and grab bars• lock bathrooms and non-supervised areas

if allowed• eliminate drop ceilings and other means of

hanging: sheets, pants, belts, shoelaces,pantyhose, bathrobe sash, towels, draw-strings from clothing, cords

Smothering hazards — eliminate plastic show-er curtains, trash liners, disposable gloves.Eating utensils — replace with plastic cutlery,paper plates, bowls and cups.Glass — eliminate by laminating pictures, orusing safety glass or Plexiglas.Jumping risks — minimize by ensuring thatwindows are tempered, shatter resistant andcannot open more than a few inches, and byalarming doors leading to the roof.Elopement risk — minimize by assigning thepatient to a room that is easy to observe andaccess, away from exits. Admit the patient toa more secure location as soon as practical, ifindicated.Patient’s belongings — immediately sepa-rate, search and sequester potentially harm-ful items (weapons, medications, drugs,sharps objects). Remove belts, shoelaces, ties,pantyhose, drawstrings from clothing;sequester personal belongings and clothingin an inaccessible area. If practical, have thepatient wear a hospital gown.

ObservationAt-risk patient suicide observation is a staff-intensive intervention. Most commonly one-to-one, observations may be constant, ran-dom, every 15 minutes, or at known places.Random observations are recommended todissuade patients from planning self-harmaround a known schedule.

The effectiveness of any observation isenhanced when it is carefully performedaccording to clear organizational policieswhich define levels of observation, requirewritten orders documenting the need forobservation, and outline exactly what mustbe observed and documented. Care plansshould be altered to suit individual patients;nurses should be free to intensify observa-tion without seeking a physician’s order; andobservation orders should be reviewed andrenewed or modified as appropriate.

Article continued on page 8

PATIENT SAFETY FALL 2007 5

PREVENTING IN-PATIENT SUICIDEEnsure a Safe Environment thruAssessment, Observation, Education

Pamela Copeland, JD, RN, BSNPatient Safety Manager

Feedback and Suggestions Based on Your ReportingNEWS FROM THE PATIENT SAFETY CENTER

Example of how a door can be used as anattachment point for hanging. Photo reprintedfrom May 2005 publication: Kenneth R. Yeager, RaduSaveanu, Albert R. Roberts, Gabby Reissland, Dan Mertz,Avni Cirpili, and Ron Makovich (2005). Measured Responseto Identified Suicide Risk and Violence: What You Need toKnow About Psychiatric Patient Safety Brief Treatment andCrisis Intervention., May 2005; 5: 121 - 141.

Model showing how even a call buttoncord can be used for hanging by an at-riskpatient. Photo reprinted from May 2005 publication:Kenneth R. Yeager, Radu Saveanu, Albert R. Roberts, GabbyReissland, Dan Mertz, Avni Cirpili, and Ron Makovich(2005). Measured Response to Identified Suicide Risk andViolence: What You Need to Know About PsychiatricPatient Safety Brief Treatment and Crisis Intervention., May2005; 5:121-141.

The US Army Dental Command receivednational recognition when it displayed thefirst-ever dental patient safety promotionbooth at the AMSUS (The Association ofMilitary Surgeons of the U.S.) ConferenceNovember 12-15. Staffed by Ms. RobertaSjelin, MEDCOM Patient Safety Coordina-tor, the booth is being used to promote newArmy Dental patient safety initiatives, usingthe theme: “A Full Time Commitment, Not APart Time Practice.”

Hardly a stranger to patient safety, the ArmyDental Command has sponsored patientsafety initiatives since 2004. While dentalsafety is not included under Joint Commis-sion oversight unless patients are hospital-ized, it is mandated under the Department ofDefense Patient Safety Program guidelines.The Army has developed a dental safety pro-gram which mirrors the larger military med-ical model. Dental officers at various facili-

ties assume safety managerial responsibilitiesin addition to their regular duties. They col-lect data on safety-related dental events andreport them monthly to a central repository.

With a history of strong support from ArmyDental Command Headquarters, the dentalsafety program has been an active partner inmilitary patient safety efforts. It has pro-duced a patient-centered brochure entitledFive Steps to Safer Dental Care aimed at rein-

forcing patients’ involvement in their ownhealth care. The five steps outlined in thebrochure encourage patients to be active intheir dental care, to share medical historywith their dentists, to discuss treatmentchoices, to understand treatment proce-dures, and to complete home care and fol-low-up plans. Currently, the dental programis developing guidelines for their own “timeout” policy, focusing on correct identifica-tion of dental patients and procedures.

6 FALL 2007 PATIENT SAFETY

Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION

ARMY DENTAL COMMAND TAKES LEAD ONPATIENT SAFETYInnovative Display Booth Introduced at AMSUS Conference

Dental Patient Safety Booth with Dental Command staff, from left to right: MAJ TimFildes (British Exchange Officer), SGM Richard Orona, COL Ann Sue von Gonten, Rober-ta Sjelin, Dental Patient Safety Consultant, and SFC Katherine Carrasco.

Five Steps to Safer Dental Care brochure, part of the Army Dental Command patient safety initiative.

PATIENT SAFETY FALL 2007 7

The spring 2007 Patient Safety ProgramNewsletter reported on the Center for Educa-tion and Research in Patient Safety (CERPS)pilot project to introduce the Microsystemsconceptual framework to the Military HealthSystem (MHS). In late 2006, staff at the NavalHospital Sigonella and Vincenza ArmyHealth Clinic completed prework, hostedthree day training sessions with CERPSinstructors, and launched initial improve-ment actions. The sites have continued towork with CERPS in supervised follow-up. Afirst year progress review recently completedby Dr. Diana M. Luan, PhD, RN, MPA, MS,CERPS Senior Research Policy Specialistrevealed process improvements and a num-ber of unexpected positive outcomes as well.

Over the last year, Dr. Luan has stayed in closecontact with each pilot site, providing guidancein monthly telephone calls. Staff have filedactivity reports each month with CERPS, andhave briefed their Commanders on a monthlybasis. Dr. Luan believes that Commandinvolvement, formalized monthly reportingand frequent documentation have been amongthe critical elements in the Microsystems-based changes. Success has also been enhancedby team stability, with each team member hav-ing at least one year of longevity. Perhaps themost fundamental element of Microsystemssuccess in these facilities has been the strongengagement of the teams. An important lessonlearned from the pilot experience is that theteam must choose a first improvement actionthat truly matters to them.

Unexpected outcomes reported by the facili-ties suggest that Microsystems-focusedchange carries the potential to generate self-perpetuating improvements. Within theteam itself, participants reported a sharperfocus on the positive, leading to concentra-tion on solutions rather than barriers. Thepilot sites also found their physicians werequite engaged in the process, and otherdepartments voluntarily asked to participatein the improvements and process. A FacilityCommander summed up the experience in

these words: “If we make these techniquesinto habits, we will naturally spread the wordon and on throughout the system.”

Currently, these sites continue to engage inthe Microsystems change process. CERPS hasbegun working with other facilities. If you areinterested in learning more about Microsys-tems and its potential to impact in your MTF,contact Diana Luan: dluan@usuhs.mil.

Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION

MICROSYSTEMS SUCCESSESPilot Centers Share Experiences of First Year

Dr. Luan leading the Microsystems team at Vincenza Army Health Clinic through theirtraining session.

Staff at Naval Hospital Sigonella outline a process they have targeted for Microsystemassessment, diagnosis, treatment and follow-up.

“Microsystems took down any

internally perceived barriers, leading

us more towards ‘how can we do

this?’ and away from ‘I don’t think

we can do this.’” Team Member

If one picture is indeed worth a thousandwords, then we want YOUR picture tohelp us tell the story of patient safety ded-ication and success in our Army, Air Forceand Navy facilities. The Patient SafetyNewsletter is planning a new feature,beginning in 2008 — the Patient SafetyPhoto Album. In each issue of theNewsletter going forward anywhere fromone to four photos of patient safety-relat-ed images will be published.

The Photo Album is intended to be a pic-torial representation of the faces of

patient safety among our DoD facilities.The photos will not be part of any article;they will be stand-along images of themany and varied patient safety effortsthat take place across the DoD MilitaryHealth System every day. From every Ser-vice, we are interested in getting to knowthe people who work so hard to makepatient safety happen — doctors, nurses,respiratory therapists, housekeepers,patient safety managers. Whatever thediscipline or occupation, we’d like toshare your efforts in an on-going photo-graphic feature.

In order to obtain photos for publicationin the Photo Album, we need your help.Please take photos of patient safety-relat-ed activities in your facility and sendthem on to the Newsletter. (A high resolu-tion jpg image works best). Photos can

show personnel at work with patients,training, or posed. Images of patient safe-ty tools, reminders and printed materialsare also welcome. There is no limit to thenumber of photos each facility can send,and no time limit for submission. ThePhoto Album will be a regular feature ofthe newsletter beginning with the Winter2008 issue. You should accompany eachimage with a caption identifying the facil-ity, the personnel pictured and the con-text of the picture.

Please send photographs to the Newsletter,attention Editor, at poetgen@aol.com. Yourphoto will be acknowledged, and you willbe notified when publication is planned.

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

of the DoD Patient Safety Program.

DoD Patient Safety ProgramOffice of the Assistant Secretary

of Defense (Health Affairs)TRICARE Management Activity

Skyline 5, Suite 810, 5111 Leesburg PikeFalls Church, Virginia 22041

703-681-0064

PATIENT SAFETY PROGRAM NEWSLETTER

Forward comments and suggestions to:DoD Patient Safety Center

Armed Forces Institute of Pathology1335 East West Highway, Suite 6-100

Silver Spring, Maryland 20910Phone: 301-295-7242

Toll free: 1-800-863-3263DSN: 295-7242 • Fax: 301-295-7217

E-Mail: patientsafety@afip.osd.milWebsite: http://dodpatientsafety.usuhs.mil

E-Mail to editor: poetgen@aol.com

DIVISION DIRECTOR,PATIENT SAFETY PROGRAM

COL Steve GrimesDIRECTOR, PATIENT SAFETY CENTER

Geoffrey Rake, MDDIRECTOR, CENTER FOR EDUCATION

AND RESEARCH IN PATIENT SAFETYEric S. Marks, MD

DIRECTOR, HEALTHCARE TEAM COORDINATION PROGRAM

Ms. Heidi King

SERVICE REPRESENTATIVESARMY

LTC Robert DurkeeNAVY

Ms. Carmen BirkAIR FORCE

Lt Col Kathryn RobinsonPATIENT SAFETY PROGRAM NEWSLETTER EDITOR

Phyllis M. Oetgen, JD, MSW

8 FALL 2007 PATIENT SAFETY

Safe Transfer Transferring patients at risk for suicidewithin the facility or to another facilityrequires a well-coordinated and clearlydefined patient handoff. The ECRI Insti-tute recommends a higher level of obser-vation during transfer; communicatingthe patient’s suicide risk to transportingand receiving staff; reinforcing to themtheir responsibility to keep the patient safeand the means they may use to addressand/or de-escalate a crisis. Off campustransfers are safest via ambulance, withone-to-one attendance. If another vehicleis used, assess it for items that may causeself-harm; use added safety precautions,such as safety locks; and increase atten-dance to two-to-one.

EducationEnvironmental safety encompasses staffresponse to self-harm events. Promptresponses and efficient interventions mayreduce the lethality of the suicide attempt.Suggestions for improving staff responseinclude drills using mock scenarios and

reviewing actual suicide events as a teach-ing tool. Reinforce best practices for rescu-ing and recovering an individual.

Patient and family education, a vital com-ponent of the team approach to promotinga safe environment, must be implementedat the beginning of the patient encounterand continuously reinforced through dis-charge. At risk patients must be assuredthat personal and environmental depriva-tions are a non-punitive component oftheir evolving care plan. Since family mem-bers and visitors may unknowingly intro-duce potentially lethal items to the at-riskpatient, staff must be alert to all visitorencounters, using them as an opportunityto both educate and protect.

For more information on ensuring a safe envi-ronment and for reference material, contactauthor at: Pamela.Copeland@afip.osd.mil

PREVENTING IN-PATIENT SUICIDEContinued from Page 5

YOU OUGHT TO BE IN PICTURES! Send Your Photos to the Patient Safety Photo Album