PATIENT SAFETY HIGHLIGHTS FROM MHS CONFERENCE

WINTER 2008 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

INSIDE: Patient Safety Awards Supplement

2008 Tri-Service Survey Plans

WINTER 2008

3 PSC Human Factors Corner4 Patient Safety Album5

Awards Presentation, Breakout Sessions Feature Patient Safety Activities

Patient Safety Award Photos

Implementation of System Changes orInterventions22nd Medical Group, McConnell AFB, KS Ruth M. Eckert, Chief, PerformanceImprovement, receiving Patient SafetyAward from Dr. Smith, Dr. Jones and LtGen James G. Roudebush, Surgeon Gen-eral, USAF.

The 2007 Patient Safety Awards were formally presented atthe Military Health System (MHS) Conference in Wash-ington, D.C. The Conference, held January 28 through 31

brought together MHS components and partners from aroundthe world for four days of general sessions with Executive Lead-ership, targeted breakout sessions, exhibitions and poster presen-tations. Especially exciting this year was a plenary session titledGrand Rounds From the Front Line which linked commandersfrom remote, deployed locations in a virtual panel discussion oftheir challenges and successes, and a special screening of FightingFor Life, a new film interweaving stories of military doctors, nurs-es and medics and the wounded warriors they serve, (seewww.fightingforlifethemovie.com for nation-wide screen datesand locations.)

The traditional awards ceremony, held on Wednesday morning,featured Dr. Stephen L. Jones, DHA, Principal Deputy AssistantSecretary of Defense (Health Affairs), Dr. Jack Smith, ActingDeputy Assistant Secretary of Defense for Clinical and ProgramPolicy and Acting Chief Medical Officer for TRICARE Manage-ment Activitiy, and each service Surgeon General presenting the2007 Patient Safety Awards to representatives of the recognizedfacility. Pictured at left are the official photos of the awardspresentation, courtesy of Austin Camacho, Deputy Director,Public Affairs Office, TRICARE Management Activity.

While the Patient Safety Awards presentation was the most dra-matic recognition of the importance of safety-related activitiesthroughout the MHS, patient safety efforts had a visible pres-ence in all of the various Conference venues.

Several breakout sessions featured patient safety initiatives, manyof which have been publicized in the Patient Safety Newsletterover the past year. The Patient Safety Awards breakout sessionprovided a well-attended forum for presentation and discussionof the five award-winning initiatives. Dr. Jack Smith, Acting

Use of TechnologyMadigan AMC, Tacoma, WA Dr. Smith, Dr. Jones and LTG Eric B.Schoomaker, Surgeon General, USA pre-sent Patient Safety Award to MAJ ShadDeering, Medical Director, Andersen Simu-lation Center.

Implementation of System Changes orInterventionsUS Naval Hospital Sigonella, ItalyHospital Commander CAPT Helen V. Pearl-man, accepts Patient Safety Award from Dr.Smith, Dr. Jones and VADM Adam M.Robinson, Jr., Surgeon General, USN.

Use of Technology49th Medical Group, Holloman AFB, NMLt Col Garry Feld receiving Patient SafetyAward from Dr. Smith, Dr. Jones and LtGen James G. Roudebush, Surgeon Gen-eral, USAF.

Improvements to Team Performance59th Medical Wing, Wilford Hall MC,Lackland AFB, TXCapt Jose L. Sanchez, NC accepts PatientSafety Award from Dr. Smith, Dr. Jones andLt Gen James G. Roudebush, SurgeonGeneral, USAF.

Deputy Assistant Secretary of Defense forClinical and Program Policy and ActingChief Medical Officer for TRICARE Man-agement Activity attended the breakout ses-sion. Dr. Smith congratulated all the presen-ters and the facilities they represented, andpresented each with a commemorative coinfrom the Office of the Chief Medical Officerin recognition of their outstanding contribu-tions to patient safety. Below is a list of thepatient safety-related breakout sessions:

Innovations In Patient Safety: 2008 Departmentof Defense Patient Safety Awards (COL StevenGrimes, AN, USA and award recipients)The Clinical Microsystem Framework: Its

Impact on Process Improvement, with Practi-cal and Measurable Change (Eric S. Marks,MD; Diana Luan, PhD, MPA, MS)Developing A Rapid Response Team: A Focuson Patient Care (LTC Eric Crawley, MC, USA)TeamSTEPPS — Training Applications forEmergency Obstetrics and Forward OperatingSurgical Team (LTC Donald W. Robinson,MC, USA; MAJ Shad Deering, MC, USA)TeamSTEPPS Training — Parts I and II(COL Sherry Ferguson, AN, USA; Dr. TimMcGuirk; Ms. Heidi B. King, MS, CHE)Potential Use in the Military Health System —National Healthcare Safety Network (NHSN)(CAPT Teresa C. Horan MPH, USPHS, CDC)Access www.health.mil to see breakout ses-sions on-line.

The Poster Exhibit included, as two of its sixcategories, Quality and Effective Patient

Partnerships, both of which enhance theoverall safety of patients. Winning the cate-gory of Patient Partnerships was a postersubmitted by Ms. Nancy Radebaugh ofDarnall Army Medical Center, entitled“Ambulatory Medication Reconciliation: APrescription for Partnership”. The posterdepicted the success of the wallet card writ-ten medication list patients carry at Dar-nall. The card is reviewed and updated at allmedical encounters, and its use ensurescommunication of all therapies to thepatient care team.

The DoD Patient Safety Program (PSP) andthe Healthcare Team Coordination Program(HCTCP) displayed their booths in the Exhi-bition Hall. New this year was the DentalPatient Safety Booth, a US Army DentalCommand initiative featured in the Fall 2007

2 WINTER 2008 PATIENT SAFETY

PATIENT SAFETY CON-FERENCE HIGHLIGHTSContinued from Page 1

CDR Tanya Ponder, NC, USN explains the Clinical Microsystems initia-tive submitted by US Naval Hospital, Sigonella at the Patient SafetyAwards breakout session, MHS Conference.

Presenters of the Patient Safety Awards initiatives pose following theMHS Conference breakout session with COL Steven Grimes, Director,DoD Patient Safety Program and Dr. Jack Smith, Acting Deputy Assis-tant Secretary of Defense for Clinical and Program Policy and ActingChief Medical Officer for TRICARE Management Activity. Pictured fromleft to right are: CAPT Jennifer Baker, Chief of Pharmacy, 49th MedicalGroup, Holloman AFB, NM; COL Grimes; Capt Jose L. Sanchez, NC,USAF, 59th Medical Wing, Wilford Hall MC, Lackland AFB, TX; Dr.Smith; Ruth Eckert, Chief, Performance Improvement, 22nd MedicalGroup, McConnell AFB, KS; MAJ Shad Derring, MC, USA, MedicalDirector, Andersen Simulation Center, Madigan AMC, Tacoma, WA.

Award winning poster, submitted by Ms. Nancy Radebaugh, depictingthe Medication Reconciliation initiative at Darnall AMC, Ft. Hood, TX.

DoD Patient Safety Program and HCTCP booths. Pictured are DianaLuan, PhD, RN, MPA, MS, Sr Research Policy Specialist CERPS and PaulHoerner, Lt Col USAF, BSC, Deputy Director, DoD Patient Safety Center.

Plans for the deployment of the 2008DoD Tri-Service Survey on PatientSafety are underway. In 2005/2006,

DoD deployed the first round of the surveyto assess the culture of patient safety withinMilitary Health System (MHS) facilities.Until that time, limited tools to assess patientsafety culture had been available to DoD.

The DoD Tri-Service Survey on Patient Safe-ty, sponsored and funded by TRICARE Man-agement Activity (TMA), is a web surveydesigned to assess staff opinions about issuesrelated to patient safety, medical errors, andevent reporting in the MHS. All staff workingin Army, Navy, and Air Force Military Treat-ment Facilities (MTFs) and dental treatmentfacilities worldwide will be asked to completethis survey. Rollout is scheduled for March2008 with results available in September 2008.

The survey assesses the following areas ofpatient safety in Military Health Systemfacilities:• Overall perceptions of patient safety• Frequency of reporting events• Management support for patient safety

• Supervisor/manager expectations &actions promoting patient safety

• Organizational learning/continuousimprovement

• Teamwork within work areas• Teamwork across work areas• Communication openness• Feedback/communication about error• Nonpunitive response to error• Staffing issues• Issues related to handoffs & transitions

Group survey results will be reported at thefacility and Service levels, as well as the MHSoverall. Feedback comparing trends betweenthe 2005/2006 and 2008 survey results will beprovided. Strengths and areas for improve-ment will be identified. The results will helpthe DoD assess the status of patient safetyimprovement efforts within MHS facilities,raise staff awareness about patient safety, andmeet requirements of the Joint Commission.

Results from the 2005/2006 survey were usedthroughout the MHS to help develop nextstep strategies to improve patient safety.Overall, 53% of all MHS staff (62,548

respondents) completed the 2005/2006 sur-vey. Most respondents (80%) gave their workarea either an “A -Excellent” or a “B -VeryGood” patient safety grade. Nine of the 12survey areas received a 50% or better positiveresponse; only 3 areas fell below 50%.

Teamwork Within Work Areas, Supervisor/Manager Expectations and Actions PromotingPatient Safety, and Management Support forPatient Safety were considered strengths.Areas for improvement included Handoffsand Transitions, Staffing, NonpunitiveResponse to Error, and Number of EventsReported. Detailed results from the 2005/2006 survey were published in the Summer2006 issue of the Patient Safety ProgramNewsletter.

The success of the upcoming March 2008survey depends on the participation of allMHS staff. Please contribute to the results byparticipating in the survey. For any questionsor comments, please contact Mr. MichaelDatena (RPh), DoD Patient Safety Program,at michael.datena@tma.osd.mil.

PATIENT SAFETY WINTER 2008 3

Spring Rollout Planned for Web-based Assessment Tool

DoD 2008 TRI-SERVICE SURVEY ON PATIENT SAFETY

"The DoD Patient Safety Program is dedicated to improving patient safety

across the Military Health System (MHS). After the 2001 official launch of the

DoD Patient Safety Program, the 2005 survey provided a first-time assessment

of the safety culture within the MHS.

We aim to learn from the 2005 and 2008 survey results, making comparisons

where appropriate, to enable open discussions regarding the culture of safety in

our system and how we can continuously work together to further improve it."

—Jack Smith, MD, MMMActing Deputy Assistant Secretary of Defense for Clinical and Program Policy

United States Department of Defense Military Health SystemJanuary 2008

Have you ever needed to complete aFMEA, but have felt overwhelmedchoosing a topic? You are not alone.

FMEAs can be overwhelming, but there areuseful tips that can help focus your FMEAprocess, narrow the scope, and make theFMEA a manageable undertaking.

Since 1 July 2001, the Joint Commission hasrequired accredited institutions to performat least one proactive risk analysis on a highrisk process within a facility.1,2 As opposed toreactive analytical methods that respond toan adverse event once it has occurred,prospective analyses are systematic methodsthat anticipate, identify, and respond to waysin which a process or product could fail.Through redesigning and mistake-proofingcritical processes, potential risks and unsafevariances are eliminated or mitigated beforethey lead to an adverse event.

Failure Modes and Effects Analysis (FMEA)satisfies the Joint Commission requirementand is the most common prospective riskanalysis method used within the MHS. Itcan be argued that “if FMEA could doexactly what it is claimed to be, there wouldbe no need for RCA”.3 However, FMEAs arenot simple, effortless processes. They canbe time-consuming and unwieldy withoutproper direction. It is important to definethe process, purpose and goals for complet-ing the FMEA early in order to efficientlymanage time and resources. Identifying anappropriate high risk process and control-ling the scope of the FMEA is paramount.

How to Choose a High-Risk ProcessDue to their complexity, high risk process-es have a higher chance for adverse patientsafety outcomes if a process or product fail-ure occurs3. Healthcare facilities often havemany high-risk processes to choose fromand the most critical process may be incon-spicuous against equally error-ridden orhigh risk candidates.

Honing in on a FMEA topic can be guidedby considering the following questionsgenerated by the Joint Commission1:

“Which process is most likely to affect thesafety of patients served?”

“Which process has the highest potentialvolume and, thus, the greatest likelihoodfor safety ramifications?”

“Which process is most interrelated toother health care processes and, thus, ifproblematic, is most likely to affect mul-tiple processes?”

High risk processes can differ among facil-ities. Look within your own facility to seewhat processes are critical and relevant tothe facility. The box above outlines helpfulresources in identifying high risk processes.FMEA teams can spend a great deal of time

and angst trying to find the absolute, mostcritical high-risk process to review. If youare having difficulty identifying a standouthigh-risk process to consider, keep in mindthat most high-risk processes would bene-fit from a FMEA review, and other high-risk processes and sub-processes can beslated for review in future years.

How to Narrow the ScopeOnce a high-risk process has been selected,there is a natural tendency to want to eval-uate and “fix” the entire process at once.High-risk processes are highly complex. Itis often too overwhelming and time-con-suming to consider each component.FMEA teams can experience burn-out,become lost in the process, or produce anineffective and incomplete FMEA. Identify-ing and evaluating one component of theprocess that is deemed most error-prone is

4 WINTER 2008 PATIENT SAFETY

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

THE HUMAN FACTORS CORNERNarrowing Your FMEA Scope

Erin Lawler, MS

FMEA TOPIC GENERATORS

Within Your Facility• Introduction of a new process or product• Changes to the design of a product, process, environment, workflow, etc• Changes to the relationship of one process component/step to other components• Initiation of new policies, procedures, regulations• Staff/patient feedback• Internal data tracking and near miss reports within facility

Patient Safety Center• Root cause and FMEA information provided in Patient Safety Center Quarterly and

Annual Reports• Monthly Summary Reports• Safety Alerts

National/International Resources• Error-prone processes indicated in literature• National Patient Safety Goals and root causes reported by the Joint Commission • Sentinel Event Alerts (www.jcaho.org)• Institute for Healthcare Improvement (IHI), Institute for Safe Medication Practices (ISMP),

National Patient Safety Foundation (NPSF) and other professional organizations

(Information sources 1,4)

Article continued on page 6

PATIENT SAFETY WINTER 2008 5

Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION

Patient Safety: All Day, Every Day Across the MHS

PATIENT SAFETY PHOTO ALBUM

The photos and images below are the first in what is intended as a regular feature of the Patient Safety Newsletter. We recognize thatproviders across the Military Health System (MHS) are working day in and day out, in ways large and small, to improve and sustainpatient safety. While not every effort rises to the level of an initiative, innovation or program, every effort makes our patients safer

and makes medical care across the MHS more valuable. We want to capture and publish these safety moments as a way of sharing the manyMHS successes and as a way of saying thank you to our dedicated caregivers.

3rd MDG, Elmendorf AFB, AlaskaPatient Safety Manager Carole Durantsends this photo with word that during2008 the 3 MDG will focus on Team-STEPPS briefs, debriefs and team huddlesthroughout the facility. Pictured conduct-ing a morning Brief are Multi-ServiceUnit staff members A1C Bowling, Lt Mor-ris, Lt Dunlevy and Capt Walking Eagle.

AMC TeamSTEPPS ActivitiesFrom Lynette M. Bell, RN, Lt Col (Ret),HQ/SGOQ, Scott AFB, Il comes thisphoto montage picturing AMC ambula-tory clinics performing TeamSTEPPS brief-ings, debriefings and huddles. Picturedare: 436 MDG Pharmacy Dover AFB; 43MDG Flight Medicine Clinic Pope AFB;437 MDG Family Practice CharlestonAFB; 375 MDG Flight Medicine ClinicScott AFB; and 60 MDG Patient Simula-tion Center Travis AFB.

35th MDG, Misawa AFB, Japan The Rapid Response guerney developedby the 35 MDG as part of their IHI initia-tive is pictured here. Patient Safety Man-ager Paul Sayles explains that the RapidResponse team answers all calls with thisfully equipped guerney, which makespatient transfers, when they are neces-sary, more timely and more easily coordi-nated.

20 MDG, Shaw AFB, South CarolinaPatient Safety Group at Shaw AFB arepictured as they gather to work onimproving the medication reconciliationand check-out processes. Pictured, leftto right are: back row, Lt Col Busch, SSgtMcLivain, MSgt Belen, Capt Marshall;front row, Mrs. Holder, Mrs. Murray, TSgtShingleton, SSgt Clemens. Photo courtesyof Shaw Patient Safety Manager RobinShingleton, TSgt, USAF.

The National Patient Safety Foundation issponsoring its annual National PatientSafety Awareness Week March 2 to March8, 2008. This national education andawareness-building campaign is meant tohighlight efforts to improve patient safetyon the local level. Hospitals and healthcare organizations nationwide are urged toplan events to promote patient safety with-in their organizations. A focus on educat-ing patients to become involved with theirown health care, as well as building part-nerships between hospitals and theirpatient communities is encouraged.

As in past years, the DoD Patient SafetyProgram enthusiastically supports NationalPatient Safety Awareness Week. Last yearmilitary treatment facilities (MTFs) acrossthe Military Health System celebrated theweek’s theme with creative activities thatincluded patient safety-related games,poster displays, demonstrations and socialevents for staff and patients alike. (SeeSpring 2007 issue DoD Patient SafetyNewsletter for photos and descriptions) AsMTFs hold activities to celebrate this year’stheme, which again is entitled “A RoadTaken Together”, we encourage you to takephotos. Please send them, along with adescription of your events, to the Newslet-ter (poetgen@aol.com) for publication inour next issue.

PATIENT SAFETY WEEK REMINDER

YOU ought to be in pictures! Send yourpatient safety snapshot to: poetgen@aol.comor to your service patient safety representativefor publication in the Spring Newsletter.

recommended. Other components of theprocess can be resumed and reviewed infuture FMEA efforts, and it would beimportant to do so.

Following these FMEA tips in the illustra-tion above will help you keep the FMEAprocess a manageable, efficient and effectivetool for improving healthcare processes inyour facility. The Center for Research andEducation in Patient Safety (CERPS) offersa half-day course on conducting FMEAs(http://dodpatientsafety.usuhs.mil.) Formore information on FMEAs , please con-tact Erin Lawler (lawlerl@afip.osd.mil;301-295-8125.)

1) The Joint Commission on Accreditation ofHealthcare Organizations. (2005). FailureModes and Effects Analysis in Health Care:Proactive Risk Reduction (2nd ed). JointCommission Resources. 2) Rich, D.S. (2001). Complying with theFMEA Requirements of the New Patient Safe-ty Standards. The Joint Commission onAccreditation of Healthcare Organizations.3) Senders, J.W. (2004). FMEA and RCA:the mantras of modern risk management.Qual Saf Health Care, 13, 249-250.4) The Joint Commission on Accreditation ofHealthcare Organizations. (2005). Systemsanalysis: prioritizing processes for FMEA.Joint Commission Perspectives on PatientSafety, 5(5). Joint Commission Resources.

6 WINTER 2008 PATIENT SAFETY

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

Ms. Susan BrockmanPATIENT SAFETY PROGRAM NEWSLETTER EDITOR

Phyllis M. Oetgen, JD, MSW

Tip 1: Flowchart your high-risk process. (This is a partial illustration for display purposes)

Establishplan of

care

PrescribeMedica-

tion/OrderLab Tests

Processorder

Prepareorder/

Dispense

Administerdrug

Monitor Patient education/Self admin-

istration

Discharge

Send order to

pharmacy

Enter intocomputer

Evaluate safety/appropriateness

of order

Tip 2: If the processhas many steps or if eachprocess step has manysub-steps, consider whichstep has the most knownweaknesses, greatest riskfor error, and greatestimpact on patient safety.This will help you identifywhich process step to further evaluate

Tip 3: Flowchart the sub-steps or sub-processes of that process step

Tip 4: Proceed with FMEA process of determining failure modes, causes, etc for each sub process step

(Cont.)

}

THE HUMAN FACTORS CORNERContinued from Page 4

This Anticoagulant FMEA example illustrates tips for narrowing the scope to one process compo-nent or step if the process is too complex. Information from ISMP Anticoagulant FMEA, ismp.org.

PATIENT SAFETY PROGRAM WEBSITE

http://dodpatientsafety.usuhs.mil

The DoD Patient Safety Program website is atimely source of information for all health-care providers across the Military HealthSystem. You are encouraged to access thewebsite, which is frequently updated, to keepabreast of developments within the DoDPatient Safety Program. On the website youwill find a "What's New" section and a"What's New Archive" link.

Easy access to the current Patient SafetyNewsletter, as well as the newsletter archive,is contained on the website. Related to thisWinter 2008 issue, you will find past PatientSafety Award articles dating from the firstaward presentation in January, 2004. Inback issues, you can also read more aboutTeamSTEPPS (Spring and Fall 2006, Sum-mer 2007); Rapid Response Teams (Spring2007) and the Tri-Service Survey Results(Summer 2006).