SPRING 2007 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
The National Patient Safety Foundation tance of correct patient identification. Their 10th MDG
encouraged hospitals and health care theme, We won't gamble with your safety, US Air Force Academy, Colorado
organizations nationwide to participate permeated varied activities, from gaming Although Patient Safety begins with an “S”, it
in Patient Safety Awareness Week chip buttons, to posters, tent cards, laminat- starts with YOU! This is the winning entry,
(PSAW) March 4-March 10, 2007. Med- ed signs and electronic message boards. submitted by the Neurology Clinic, in the
ical Treatment Facilities (MTFs) across Training, patient safety leadership rounds 10th MDG patient safety slogan contest,
the Military Health System responded and commander's calls further spread their which culminated its PSAW activities. While
enthusiastically, focusing patients and message and reinforced their commitment staff played Patient Safety Poker and enjoyed
staff alike on patient safety and high- to accurate patient identification. a patient safety scavenger hunt during the
lighting the collaborative nature of build-
ing a safe environment. The Patient Safe- 325 MDG
ty Program salutes the Patient Safety Tyndall AFB, Florida
Managers and all staff whose participa- Patients at the 325th MDG were provided
tion made these activities successful. with information on safe medication use.
Staff participated in a rousing game of
99th MDG “Squadron Patient Safety Feuds” during a
Nellis AFB, Nevada March 7th commander's call. Weeks of prepa-
The Patient Safety Working Group at Mike
O'Callaghan Federal Hospital capitalized
SPRING 2007
T
he National Patient Safety Goals ments and providers for quick reference. To accurately and completely reconcile
(NPSGs) were developed to minimize • Distributing ID badges with list of the medications across the continuum of care6
medical errors and to promote specif- unapproved abbreviations on the back. is a laborious task. This goal was created
ic improvements in patient safety. Since • Laminating copies of the “do not use in 2005 and is still being implemented.
2003, the Joint Commission has surveyed abbreviation” list, with acceptable alter- MTFs suggest:
accredited medical treatment facilities natives. Place in each patient's chart and • Create a multi-functional team to design
(MTFs) and checked for the implementation next to department telephones to assist an effective and efficient medication rec-
of the NPSGs. Each year the Joint Commis- with verbal orders. onciliation (MR) process. Have Patient
sion reports the compliance rates for goal • Printing “do not use abbreviation” Safety Managers collaborate for regional
implementation. The 2006 2nd quarter list on florescent-colored paper as a or service specific lessons learned.
NSPG compliance rate for all accredited hos- visual reminder. Post wherever orders • Start the MR process when the admit-
pitals was below 80% for goals 1B, 2B, 2C, are written. ting nurse prints the inpatient admis-
and 8A1. The Patient Safety Center (PSC) has • Placing adhesive backed “do not use” sion MR form, reviews meds with
reviewed relevant literature and information abbreviations cards on/near each com- patient, and determines with provider
from MTFs on these goals and offers the fol- puter as a reminder to staff performing meds to be continued, stopped, or held
lowing actions and lessons learned to assist data entry. during admission. Place copy of MR
with implementation and/or compliance. form in chart. Have Pharmacy print out
Goal 2C. discharge MR form and review drugs
Goal 1B. Critical test results and values must be report- with patient. Utilize both Summary of
“Time out”, part of the universal protocol ed in a timely fashion. These can involve labo- Care updates and outpatient drug pro-
(required after 7/1/04) for preventing wrong ratory tests, imaging studies, electrocardio- file in AHLTA
site, procedure, person surgery is essential grams and other diagnostic studies.3 To ensure • Have IT staff develop a AHLTA menu
and must be conducted immediately before timely reporting: item to retrieve a patient profile of drugs
starting a procedure.2 “Time out” has • Maintain a prioritized list of critical test dispensed from pharmacy, retail net-
expanded to include dental and separate values/interpretations that require work, and mail order (utilizing DoD
anesthesia procedures such as nerve blocks. accelerated notification. 4 Pharmacy Data Transaction Service),
To facilitate time out: • Note the criticality of tests and designate as with headings for adding over-the-
• Emphasize active communication tech- critical in the electronic ordering system. counter drugs and supplements.
niques among staff and with patient; • Include ordering physician and location Provider reviews updated form with
verbalize what is being done. on test requisitions. Ensure the labora- patient and reconciles any changes in
• Require a separate “time out” immedi- tory has a mechanism to determine on- drug therapy. At check-out patient gets
ately before an anesthetic block. call coverage.5 list of current drugs and tech updates
• Use two unique identifiers during “time • If the computer system will not allow and initials DoD Form 2766.
out” to verify correct patient. more than one person to receive the lab • To ensure compliance, conduct a ran-
• Attach a printed sign with laterality to the results, assign a surrogate provider when dom review (3-5 charts per provider)
fluoroscopy unit as a visual reminder of the PCP is not available. of patient records and documented
the side being assessed during “time out” • For systems that automatically commu- provider compliance with medication
and during the procedure. nicate results to the responsible reconciliation.
• View digital radiological image as part provider, include an acknowledgement
of the final “time out” process to function to ensure that the result was For specifics of footnote references, please con-
ensure that the radiologic images are received. Create a prompt with an alter- tact Mary Ann Davis at davism@afip.osd.mil.
properly oriented. native communication approach when
THE HUMAN
FACTORS CORNER Where HFE Can Help
Integrating Human Factors and
Designing for individual factors physical strength and dexterity; anthropometrics and biome-
Patient Safety chanics; mental workload; information processing, fatigue, lim-
itations, capabilities, expectations, etc
Erin Lawler, BA, MS
Design of work job demands; process design; communication, teamwork;
required cognitive, physical and social skills, etc
Design—the creation and/or implemen-
Design of objects technology (software/hardware); equipment; medical supplies;
tation of things—affects nearly all aspects of furniture, etc
patient safety from medical supply packaging Design of the work environment layout; ambient considerations of light, noise, temperature, etc;
to the way policies are implemented. Design organization of equipment and materials, etc
can enable the safe and effective delivery of Organizational factors macroergonomics; safety culture; norms; organization type,
health care or it can significantly impede it. goals; resource availability; allocation of functions, etc
Can a process be better organized in terms of the tasks, team work, and work flow needs? Can a process be
You may at times use medical devices simplified and made clearer?
that seem needlessly complex or find that you
Can equipment and medical supplies be better arranged according to frequency of use?
spend significant time walking back and forth
as you gather medical supplies. Lack of con- Is the work environment layout flexible and supportive of work patterns and tasks? Can the layout be
improved to reduce moving back and forth? Are there areas that are difficult to navigate?
sideration for the interaction of a person with
the equipment, spaces and people around Is there equipment or technology that is difficult to use or easy to misuse (physically and mentally)? Do you
have all the necessary information from the technology to make appropriate decisions?
him or her can produce negative conse-
quences that range from staff frustration, Are lighting and acoustics optimal for the work? Are signals and warnings difficult to hear or see?
T
he Department of Defense Patient the Welcome page, to designate CERPS (pur- have accessed the site, please bookmark it for
Safety Program (PSP) launched its ple), the PSC (red) and HCTCP (teal). A frequent return. It is intended to be a timely
new website in April 2007. The site is drop-down menu under each of these Pro- source of information on the Patient Safety
designed to support the mission and pur- gram components allows users to see the Program, its products, services and compo-
pose of the Patient Safety Program, as well content of each component at a glance. nents. It will serve as a repository of the
as to support the individual and collective Finally, News flashes are repeated below the Patient Safety Newsletter and other Program
missions of the Center for Education and left navigation bar in each section, so that publications, and will provide a link to exter-
Research in Patient Safety (CERPS), the timely information is accessible without the nal Patient Safety news.
Patient Safety Center (PSC) and the need to return to the Home page.
Healthcare Team Coordination Program
(HCTCP). Development of the Patient
Safety website is a three-phase project. The
currently available Phase 1 provides public
level access. Phase 2 will focus on user
groups, and will provide login capability to
view user specific and/or protected data
materials. The third phase will incorporate
interactive capabilities.
A
re you working in an overwhelmingly
busy clinic or department where,
despite your best efforts, inefficien-
cies and frustrations seem the order of the
day? Have you often thought that you'd like
to improve how things work but you are so
busy doing your job that you don't have the
time? If your answers are yes, as they are for
staff in most complex health care environ-
ments, you should be particularly interested
in learning more about the microsystem
framework and its potential for transform-
ing patient care from the inside out.
Slide from CERPS microsystems training illustrating the elements of the microsystem
In recent years, the microsystem has become a
focal point in efforts to improve health care. supports microsystems-based change takes found in the marketplace, microsystems is a
Defined as “the small, functional, front-line the work of Improvement (both quality and conceptual framework. Dr. Luan explains
units that provide most health care to most safety) and reduces it to the smallest repro- that its implementation requires only
people”(Nelson EC, et al, Jt Comm J Qual Improv 28) ducible unit—the SRU(Quinn, J. B. (1992). The curiosity, dedication and a willingness to
microsystems are the local milieu—the indi- intelligent enterprise. New York, Free Press)—the inter- look at ourselves and what we do every day
vidual department, clinic, or small group of face with the patient. The goal of a highly with a new set of lenses. As powerful as it is
people working together on a regular basis to functioning microsystem is to ensure that simple, focusing on the microsystem facili-
provide care to a discrete population of each patient interface is the most effective, tates positive change one step at a time,
patients. Microsystems are the place where most efficient, most productive possible. To beginning with each patient, each one of us,
patients and providers meet. Recognition is accomplish this, those working in the and each task we perform in our efforts to
growing that the quality and value of care microsystem reflect on the four P's—People, provide care.
produced by a large health system can be no Patients, Processes and Patterns (measure-
better than the services generated by the small able outcomes)—of their particular unit. If a
systems of which it is composed. unit understands all that is involved in the
four Ps, it is better able to tailor services to PATIENT FALL PREVENTION UPDATE
More Details in Summer Newsletter,
The Center for Education and Research in the patient. Described as the “elementary Focused Review
Patient Safety (CERPS) began a pilot project school” for further improvements by Dr.
in late 2006 at the Naval Hospital, Sigonella Luan, assessing the microsystem does for the The Eighth Annual Patient Falls Conference,
and Vincenza Army Health Clinic to test work environment what medical providers titled “Transforming Fall Prevention Prac-
whether and how the microsystems concep- do daily in the clinical environment—it tices”, was held April 15-18, 2007 in Clear-
tual framework can be successfully assimilat- identifies the basic steps in providing service, water, Florida.
ed into the Military Health System. Com- assesses how they work, diagnoses and treats
mand support was obtained, the pilot units problem areas, and follows-up to ensure The DoD Patient Safety Center (PSC) will
completed prework and created a team rep- there is no relapse. The information summarize findings identified during the con-
resenting every role in their units. CERPS obtained from assessing in detail the exact ference in the next Newsletter. In mid July
then held a three day training visit at each steps taken to deliver care to patients is used 2007, the PSC will publish a Focused Review
site, where teams identified gaps or ineffi- to improve, correct and change problems featuring an analysis of patient falls within
ciencies in how they worked, and launched and standardize functioning. DoD and strategies for enhancing existing
their first Improvement Action. Over a year patient fall prevention programs at the MTF
of CERPS supervised follow-up, further Microsystems-focused thinking is a decep- level. This information will enable facilities to
improvements are expected within the units, tively simple concept that builds the foun- ably comply with the 2007 National Patient
with team members being responsible for dation for wide-spread system change and Safety Goal 9B—Implement a fall reduction
continual assessment and positive change. improvement. It makes the mandate to cre- program—including an evaluation of the
Dr. Diana M. Luan, PhD, RN, MPA, MS, ate efficient, highly reliable systems doable effectiveness of the program.
Senior Research Policy Specialist at CERPS by bringing change down to the personal
explains that the conceptual framework that level. Unlike toolkits and patented products
RR > 24
In the near future, Hospitalists will be that our staff are better able to recognize DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM
incorporated into the team. A Pediatric subtle findings leading to the earlier iden- COL Steve Grimes
RRT is being developed. We will be using tification of clinical deterioration and that DIRECTOR, PATIENT SAFETY CENTER
Geoffrey Rake, MD
automatic clinical alerts from the electron- when recognized, those staff now have a DIRECTOR, CENTER FOR EDUCATION
ic medical record system to help increase means of rapidly marshalling help. We AND RESEARCH IN PATIENT SAFETY
Eric S. Marks, MD
identification of patients meeting RRT believe that the RRT nurse in particular DIRECTOR, HEALTHCARE TEAM
trigger criteria. In recognition of the value brings expertise to the bedside in support COORDINATION PROGRAM
Ms. Heidi King
of patient and family concerns, effective of an increasingly junior and transient
SERVICE REPRESENTATIVES
June 1, 2007 a Family Brochure explaining nursing staff. The institutional expectation ARMY
the RRT will be given to all patients during that the RRT will be called when trigger LTC Robert Durkee
NAVY
admission. The brochure will explain when criteria are met places the responsibility on Ms. Carmen Birk
AIR FORCE
and how a patient or family member can the staff member to seek help. The collab- Lt Col Kathryn Robinson
contact the RRT. The RRT will follow up orative essence of the team provides assis- PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
Phyllis M. Oetgen, JD, MSW
with patients and family members within tance to the primary team without com-