THIS ISSUE: DoD PATIENT SAFETY AWARDS

Patient WINTER 2004

F0011
Page 2 Patient Safety Center News

Safety
Page 4 “Hot Topics” - A Must Read
Page 5 LLINKS - PS Website Feature
Page 6 March 7-13 - Be Aware!

A quarterly newsletter to assist DoD hospitals with improving patient safety

PATIENT safety and quality; reward successful

SAFETY
AWARDS
PRESENTED
MTF Initiatives Recognized
T he first annual Patient Safety
Awards were presented at the TRI-
CARE Conference in Washington, D.C.
on January 29, 2004. The 81st
Medical Group at Keesler AFB,
Mississippi received the Technology
award; the Policy and Procedure award
went to the 355th Medical Group at
Davis-Monthan AFB, Arizona; and the
Naval Medical Center San Diego
received top honors for its Team
Training project.
patient safety efforts, particularly in the
development of a culture of safety;
inspire organizations to increase their
patient safety efforts; communicate suc-
cessful programs and strategies
throughout the MTFs. Each project is
required to describe successful system
changes or interventions designed to
make the environment of care safer,
and show outcomes expressed as errors
prevented, lives saved or avoidance of
poor outcomes.
Patient Safety Leadership Rounds, the
policy and procedure initiative submit-
ted by the 355th Medical Group at
Davis-Monthan AFB was developed to
reinforce and sustain its patient safety
culture. Like many MTFs, Davis-
Monthan has a fully implemented
patient safety program. Although they
engage in multiple sustainment strate-
gies, they realized they had no objective
measure of the on-going success of the
program. Patient Safety Leadership
Rounds, conceived by the Patient Safety
Manager and Outcomes Manager, and
enthusiastically supported by Squadron
Commanders, combines personal visits
and an anonymous, statistically valid
patient safety culture baseline survey,
the results of which can be repeated
and compared over time.
Each month one area in each of the
four medical squadrons is the focus of
Continued on page 3

The Patient Safety Awards, in the cate-

gories of Technology, Policy and
Procedure, and Team Training, will
continue as an annual honor. They are
meant to recognize leadership and
innovation in quality, safety and com-
mitment to patient care by the Military
Treatment Facilities (MTFs). The
awards were conceived as a way to
encourage four important institutional
goals: raise awareness of the need for Lt Col Richard Clark, Deputy Commander, 355 MDG/SG Davis-Monthan AFB, accepts DoD
Patient Safety Award for Policy and Procedure
organizational commitment to patient
NEWS FROM THE
PATIENT SAFETY
CENTER
Feedback and Suggestions
Based on Your Reporting
JCAHO NATIONAL
PATIENT SAFETY
GOALS AND MTF
ACTION PLANS
Safety Actions Incorporate JCAHO
Requirements
by Mary Ann Davis, RN, BSN, MSA
Nurse Risk Manager, Patient Safety Center
S pecific patient safety actions taken in
response to adverse events represent
the working spear tip of the DoD Patient
Safety Program. Sharing these actions with
Medical Treatment Facilities (MTFs) is one
goal of the DoD Patient Safety Center (PSC).
The Monthly Summary Reports submitted
by 144 MTFs supply the PSC with narrative
descriptions of actions put into place to
improve patient safety. Several of these
safety actions address Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO) National Patient Safety Goals. The
goals most frequently used in implementing
actions or modified to meet the response
required for specific patient safety prob-
lems are:

Goal #1— improving the accuracy of
patient identification

Goal #2a — implementing a process
with a verification read-back

Goal #4a — using a checklist to verify
a process
Actions related to improving the accuracy
of patient identification include the use of
two patient identifiers. Unfortunately there
are occasions when the two identifiers cho-
sen do not remedy the problem. For exam-
ple, a dependant may share the same name
and have the same last 4 digits of the social
security number as his or her sponsor.

To address this issue, one MTF uses
the patient’s date of birth in addition to
the sponsor’s name and social security
number. These identifiers are placed
on the patient’s addressograph and
wristband. Responses reported by
other MTFs include identifying patients
by name, date of birth, social security
number, and address or phone num-
ber; eliminating the bed or room num-
ber as an identifier; and asking the
patient, prior to a procedure, to state
his or her name and date of birth as
identifying verification.

Of particular note, one MTF uses green
armbands to identify patients typed
and cross-matched for transfusion.
Green was chosen to distinguish these
armbands from drug allergy and
admission bands.
Clinical laboratories receive specimens
from various areas of each MTF. These
specimens are processed and the results
are returned to the provider. Mishandling
or misidentification of specimens, while
infrequent, has occurred in different facili-
ties.

Two action plans describe a verifica-
tion process. Laboratory technicians
in one MTF confirm all the information
on the specimen and correct any prob-
lems prior to accepting the specimen.
Another laboratory modified their stan-
dard operating procedure to require a
read back by the person accepting the
verbally reported values verifying that
the information is correctly recorded
and understood. This facility also put
into place procedures for management
of critical values. Whenever critical
values are reported to the provider or
floor, the laboratory staff records in
the computer the person spoken to,
the time, date of the call, and the call
recipient’s specific response.
Patient Safety proponents encourage using
checklists to avoid relying solely on memo-
ry. Preoperative checklists are part of most
operating room standard procedures, and
checklists are increasingly being utilized in
other areas.

MTF actions range from checklists to
ensure complete and accurate docu-
mentation for dental procedures to an
environmental checklist reminding the
2
staff to be aware of building security
and to decrease the energy usage in
the facility.

Checklists are an effective way to
ensure equipment maintenance and
supplies. A Glucometer checklist is
used daily in one MTF to test working
order and the supply of testing strips.

Checklists are also being used to assist
with documentation and completion of
specific procedures that require high-
risk medication or chemotherapy.
One MTF has a list that must be
checked off as each chemical/medica-
tion is prepared and used, specially
noting concentration. This MTF’s labo-
ratory and procedure units use the
checklist to confirm delivery of speci-
mens to the lab and ensure that results
are received in a timely fashion.

Another MTF designed a daily patient
safety checklist, a modified version of
the PSC’s Monthly Summary Report.
The checklist is used to record errors
as they happen rather than recapping
the month’s events at a later date,
when errors may be forgotten or not
accurately captured.
Unrelated to the JCAHO safety goals, a
recent, noteworthy MTF action addresses
errors with look alike/sound alike medica-
tions.

An MTF Pharmacy and Therapeutics
committee revised its list of look
alike/sound alike medications, and
placed laminated copies of the list in
all in-patient charts as a reminder to
the prescriber. When look or sound
alike medications are ordered, they
are flagged and highlighted in the
computer as a warning to the pre-
scriber and pharmacy personnel.
The narrative section of the Monthly
Summary Report is a convenient tool to
help spread the safety message. Facilities
are encouraged to use this tool to stimulate
sharing of their safety actions and coopera-
tively build a safer patient care environment
for all our beneficiaries.
PATIENT
SAFETY IN
ACTION
Experiences and Suggestions Operating Room Effectiveness and
From the Field
continued from page 1 quent staff turn-over, status as a train-
patient safety rounds. The process
intentionally is an informal one. It
begins with distribution of the survey,
which is followed by a personal visit
from the squadron commander and
patient safety staff. During this walk-
thru the staff has the opportunity to
respond to open-ended questions
designed to elicit discussion about safe-
ty conditions, near misses and reporting
habits. The benefit of these sessions is
mutual – patient safety staff gain insight
into current patient safety efforts, and
staff receives a hands-on refresher
course on safety issues and reporting
techniques. Observations, recommen-
dations and issues are captured,
entered into a database and classified
according to TapRooT® Cause
Categories, and are fed back to com-
manders for action. Daniel Evans,
Director of Outcomes Management at
the 355 MDG, estimates these rounds
require a commitment of only one hour
per month for each commander. In
return, they have achieved an easy,
objective, measurable process for
charting, comparing and sustaining a
strong patient safety culture. For more
information on Patient Safety
Leadership Rounds, contact the
355MDG PSM:
Frankie.Smith@dm.af.mil, ph: 520-228-
2722 or Daniel.Evans@dm.af.mil.
Naval Medical Center San Diego
(NMCSD) adapted the familiar team
training product, MedTeams, to the
operating room and significantly
enhanced it by creating a “Pocket
Card” sustainment tool. CAPT John
Webster, MD, Chairman of the
Orthopaedic Department explains that
the decision to introduce MedTeams to
the operating room arose from the on-
going review of the Committee for
Quality. The Committee identified a
triad of challenges at San Diego – fre-
ing-teaching hospital, relatively junior
staff — which motivated them to identi-
fy communication and teamwork as pri-
orities for optimum achievement.
NMCSD had participated in the first
MedTeams implementation in emer-
gency rooms in1998-1999. This famil-
iarity, combined with MedTeams exist-
ing training, implementation and sus-
tainment plans, were key factors in the
selection of MedTeams for the operating
room.
CAPT Nancy Simmons, then chief nurse
in the operating room and now Senior
Nurse Executive, Directorate of Surgery,
coordinated the process of contacting
and working with Dynamic Research
Corporation (DRC), the creator of
MedTeams. To maximize the effective-
ness of MedTeams in the surgical envi-
ronment, a team of nurses and doctors
collaborated with DRC to modify the
existing curriculum, tailoring learning
DoD Patient Safety Award for Team Training, presented by Rear Admiral Mateczun to Captain
Nancy Simmons and Captain John Webster.
3
activities and writing vignettes applica-
ble to the operating room. They added
a truly creative element with the intro-
duction of their innovative “Pocket
Card” system, unique to San Diego,
which addresses the three-fold need for
on-going training, sustainment over
time, and data collection to objectively
measure the success of the team train-
ing effort. Each 3 3/4 x 6 inch “Pocket
Card” combines a teaching goal related
to MedTeams, patient safety or lessons
learned, and a four question Likert
scale response for measuring team per-
formance, an inspirational quote, and
limited demographic data. The cards,
completed in 30-45 seconds and col-
lected at the end of each surgical case,
are scanned, and the data is being col-
lated and aggregated. NMCSD antici-
pates measurable results from the team
training initiative by the end of this year.
In the meantime, their OR adaptation
and intriguing three-in-one “Pocket
Card” sustainment tool are already
being replicated in other Naval facilities.
For more information contact jsweb-
ster@nmcsd.med.navy.mil, ph: 619-
532-8427.
Continued on page 4
PATIENT
SAFETY IN
ACTION
Experiences and Suggestions
From the Field
continued from page 3
The Patient Safety award for Technology
recognizes that patient safety efforts,
like every other aspect of healthcare,
can be facilitated and improved by the
effective use of technology resources.
The winning initiative submitted by the
81st Medical Group at Keesler AFB uti-
lizes barcodes and barcode scanning
for lab specimen processing. The proj-
ect concept grew out of staff feedback
which targeted errors in labeling,
patient identification and delays in spec-
imen processing as particular chal-
lenges. The effort to develop a technol-
ogy driven response to the perceived
problem was fully supported by leader-
ship – both an executive champion and
the Chief Information Officer.
The key to implementation of this tech-
nological solution required overcoming
barriers related to existing technology,
as is often the case. Three different
Computerized Health Care Systems
(CHCS) devices were in use at Keesler,
requiring unique interfaces and
improvements to the CHCS software
before an integrated system could be
achieved. The use of a multidiscipli-
nary team was an important key to the
success of the project, according to
Capt Edward Cassin, 81st MG Executive
Officer. Keesler utilized its existing
CHCS Steering Committee, a multidisci-
plinary team of information systems,
clinical and laboratory staff members.
The 81st Medical Group set an ambi-
tious goal with its implementation of the
barcode scanning system for lab speci-
DoD Patient Safety Award for Technology presented to Brig Gen David G. Young III,
Commander, 81st Med Group Keesler AFB.
mens — 100% of specimens were
expected to arrive at the lab with orders
and correct patient identification labels.
Recognizing that even the best technolo-
gy requires proper use, all inpatient
and outpatient personnel were trained
in the new barcode process. Upon
implementation, the barcode system
enabled staff to correctly identify each
patient with his/her lab specimen.
Specimens without orders or with mis-
labels were counted and trended for
evidence of project success. The bar-
code scanning system has achieved a
90-95% decrease in the number of
specimens arriving at the lab either
mislabeled or without orders. In addi-
tion, the barcode scanning strategies
provide an interface with existing tech-
nology to correctly match each patient
to his/her CHCS demographic/admitting
record.
Four take-away points from Capt Cassin
capture the key to this project’s suc-
cess: form a multidisciplinary team of
key staff members; up-channel informa-
tion rapidly for command support and
guidance – an executive champion is a
must; challenge the team to innovate at
all decision points and use existing
resources to solve problems if possible;
check your progress, adjust your
course, keep your focus on the ultimate
goal of patient safety. For more infor-
mation contact,
4
Edward.Cassin@Keesler.af.mil, ph: 228-
377-7209.
The leadership of the Patient Safety
Program extends congratulations and
thanks to the dedicated professionals
who worked on all of the projects sub-
mitted to this first Award program. The
enthusiasm, creativity, time and interest
shown by everyone involved is a truly
impressive indication of the level of
expertise and care found across the
Military Healthcare System. Their proj-
ects make it clear that the real winners
are our beneficiaries, who enjoy the
care and concern of professionals and
providers who make patient safety their
business and who work to improve it
every day.
PSC INTRODUCES HOT TOPICS
The Patient Safety Center has begun the
regular publication of HOT TOPICS, an
on-line resource providing current
actionable patient safety information
from across the healthcare industry. Hot
Topics includes short summaries of
emergent patient safety issues, and is
intended to highlight practical, timely
information for providers. DoD Patient
Safety Program personnel are encour-
aged to regularly review Hot Topics and
incorporate its suggestions and actions
plans into their practice.
LLINKS SHOW-
CASES AWARD
PROJECTS
New Website Provides Project Guide
T wenty-two projects were submit-
ted for Patient Safety Award con-
sideration. Although only three could
win top honors, all of the initiatives
included creative approaches to
improving patient safety. LLINKS, a new
website created and managed by TMA,
and established for the purpose of shar-
ing Lessons Learned and Integrating
New Knowledge, contains a detailed
summary of each project. You are
encouraged to visit the site on our exist-
ing Patient Safety Web page –
http://patientsafety.ha.osd.mil - and
bookmark it for future reference. The
intent of LLINKS is to provide an infor-
mation network outlining the field of
current MTF projects to facilitate the
exchange of patient safety knowledge
and best practices across the Military
Healthcare System.
In addition to the winning projects on
this first LLINKS posting, you will find
nineteen other initiatives submitted for
the DoD Patient Safety Award:
Policy and Procedure: Naval Medical
Center San Diego- Satellite Pharmacy
in Main OR; Naval Hospital Lemoore
- Medication Management Standards;
Naval Hospital Charleston -
Medication Safety Project; Naval
Medical Clinic Annapolis - Patient
Safety Integration Throughout
Operation; BUMED Navy Dental
Corps - Dental Patient Safety Program;
55th Medical Group, Erhling
Bergquist Hospital – Establishing a
Culture of Safety; Naval Hospital
Cherry Point - Implementation of
Wrong Site Patient Safety Goal; 59th
Medical Wing, Lackland AFB –
Establishment of Psycho-educational
Program; 89th Medical Group,
Andrews AFB – Root Cause Analysis;
12th Medical Group, Randolph AFB
– Pediatric Immunization Clinic
Program; 45th Medical Support
Squadron Pharmacy, Patrick AFB –
Impact of Pharmacy-Led Dyslipidemia
Interventions on Medication Safety and
Therapeutic Failure Patients; Naval
Hospital Rota, Spain - Market
Culture of Safety With Use of Humor
Team Training: Naval Hospital
Pensacola - Aviation Safety Application
in the Hospital Setting
Technology: Naval Hospital Oak
Harbor - Occurrence Screen Database;
Naval Hospital Bremerton –
Provider Appraisal Report Database;
DoD Pharmacoeconomic Center –
Pharmacy Data Transaction Service;
375th Medical Group, Scott AFB –
Clinical Integrated Workstation; 96th
Medical Group, Eglin AFB –
PharmASIST pharmacy automation
product line; National Naval Medical
Center – Pharmacy Automation
As varied as the twenty-two award proj-
ects are, there are three fundamental
similarities amoung them. Each initia-
tive enjoyed strong leadership support.
In addition to express authorization
leadership often stayed directly involved
with the project — projects were regu-
larly reviewed at meetings, commanders
and department heads served as advi-
sors, participated in training, and made
field visits. Each project involved some
form of improving communication —
using training and feedback directly
related to performance, and building in
mechanisms for sustaining active staff
involvement in the effort. Finally, each
5
Patient Safety Links
Interesting Resources To Explore
Promoting Patient Safety: An Ethical
Basis for Policy Deliberation
www.thehastingscenter.org
The final report of the Hastings Center
research project in response to the
original IOM report; seeks to foster
discussion of the ethical concerns
integral to development and implemen-
tation of policies addressing patient
safety.
From Chaos to Care: The Promise of
Team-Based Medicine, David Lawrence,
M.D.
www.amazon.com
Perseus Publishing, Cambridge MA,
2002
The former head of Kaiser Permanente
presents case for a team-based
approach to providing medical care.
Escape Fire: Designs for the Future of
Health Care, Don Berwick, MD
www.ihi.org
Jossey-Bass, San Francisco, California,
2003
Eleven speeches on theme of funda-
mental change and revolutionary new
design for our healthcare system.
Joint Commission On Accreditation of
Healthcare Organizations
www.jcaho.org
2004 National Patient Safety Goals
Ambulatory Care Advisory, Issue 3,
2003. Recaps 2003 pilot tests of
accreditation process in ambulatory
care organizations.
VA National Center for Patient Safety
www.patientsafety.gov
Topics In Patient Safety, Dec.
2003/Jan. 2004. VA Patient Safety
newsletter presents a thorough update
on the JCAHO Patient Safety Goals for
2004, including a summary of CDC rec-
ommendations for hand hygiene.
project employed a multidisciplinary
approach in its design, implementation
or sustainment.
It is of note that lessons learned from
these global patient safety efforts mirror
those lessons that repeatedly are
learned from summary reports and root
cause analyses. Patient safety requires
the commitment of leadership, on-
going, interactive communication, and
staff integration to be successful,
whether success is measured by a good
project for the facility or a good result
for the patient.
 SPECIAL FOCUS activities and resources on its website
CONFERENCE at www.npsf.org. Ideas range from
ON SAFETY patient centered efforts like a simple
CALENDAR National Patient Safety suggestion box for patients and fami-
Awareness Week lies or distribution of patient safety lit-
3RD ANNUAL INTERNATIONAL erature to activities inviting staff input
such as surveys, information sessions
SUMMIT ON INNOVATIONS IN
CRITICAL CARE DELIVERY
March 17-19, 2004
T he third annual National Patient
Safety Awareness Week will be
observed March 7 thru March 13,
and roundtable discussions addressing
safety concerns.
Miami, Florida 2004. Endorsed by the National As is so clearly seen in the efforts
www.ihi.org Patient Safety Foundation (NPSF), showcased in this issue of the Bulletin,
Patient Safety Awareness Week is a MTFs across the Military Health System
NATIONAL PATIENT SAFETY national education and awareness- devote a great deal of time, talent and
FOUNDATION building campaign aimed at improving creativity to patient safety. This special-
6TH ANNUAL NPSF PATIENT patient safety at the local level. ly designated week offers an opportu-
SAFETY CONGRESS
With just a little extra thought and nity to share your efforts with patients,
May 3-7, 2004
effort, every MTF could actively partici- families and colleagues.
Boston, Massachusetts
www.npsf.org pate in this national focus on patient
safety. The NPSF has provided a clear-
AMERICAN SOCIETY FOR inghouse of potential and on-going
HEALTHCARE RISK
MANAGEMENT
POST CONGRESS PROGRAM
May 6-7, 2004
Boston, Massachusetts
www.ashram.org or www.npsf.org Patient
16TH ANNUAL NATIONAL
FORUM ON QUALITY
IMPROVEMENT IN HEALTH
Safety
Patient Safety is published by the Department of Defense (DoD) Patient Safety Center,
located at the Armed Forces Institute of Pathology (AFIP). This quarterly bulletin provides periodic updates
CARE on the progress of the DoD Patient Safety Program.
December 12-15, 2004
Orlando, Florida DoD Patient Safety Program
Office of the Assistant Secretary of Defense (Health Affairs)
www.ihi.org TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, Virginia 22041
703-681-0064

DoD PATIENT SAFETY WEBSITE

The DoD Patient Safety Website is now
accessible at this address:
http://patientsafety.ha.osd.mil. New con-
tent has been added. Particular attention
is called to the FAQ section, where you
will find answers to questions regarding
MedTeams training and Monthly
Summary Reports. Access past copies of
the Patient Safety Bulletin, link to patient
safety resources and contact the Patient
Safety Program. Continue to review the
website for the latest information on DoD
training.
Please forward comments and suggestions to the editor at:
DoD Patient Safety Center
Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
Phone: 301-295-8115 • Fax: 301-295-7217
E-Mail: patientsafety@afip.osd.mil • Website:http://patientsafety.ha.osd.mil
E-Mail to editor: poetgen@aol.com
DIVISION DIRECTOR, PATIENT SAFETY PROGRAM: CAPT Deborah McKay
DIRECTOR, PATIENT SAFETY CENTER: Geoffrey Rake, M.D.
SERVICE REPRESENTATIVES:
ARMY: LTC Steven Grimes
NAVY: Ms. Carmen Birk
AIR FORCE: Lt Col Beth Kohsin
PATIENT SAFETY BULLETIN EDITOR: Phyllis M. Oetgen, JD, MSW