FOCUS: TOOLS TO IMPROVE SYSTEM SAFETY
Patient
Safety
A quarterly newsletter to assist DoD hospitals with improving patient safety
PATIENT SAFETY
MANAGERS AS
TEAMWORK
CHAMPIONS
Review of DoD Team Training
by Renee Norris RN, BSN, CGRN and Lauren
Toomey RN, BSBA, MIS, Sr. Program Analysts
H ave you ever felt overwhelmed by
your day-to-day responsibilities in
leading the Patient Safety Office? Have you
felt frustrated that you haven’t been able to
be more proactive in improving the climate
and culture of safety within a specific
department, or even the hospital as a
whole?
Medical Team Training (MTT) may offer
you an opportunity to bring about change
within your organization. It provides
proactive approaches that can be employed
to improve communication and coordina-
tion among the staff, and ultimately
increase the effectiveness of patient care.
MTT may not only improve patient safety in
your facility, but also provide you with the
knowledge that you played a pivotal role in
those improvements.
Introduction to Team Training in
DoD
After the Institute of Medicine (IOM)
Report entitled To Err is Human:
SPRING
Building a Safer Health System was
released in November 1999, a demand for
action by the government, media, and the
healthcare profession ensued. In October
2000 President Clinton signed into law the
National Defense Authorization Act (NDAA)
for 2001 which mandated the creation of
the DoD Patient Safety Program. In addi-
tion to establishing the Patient Safety Center
for the collection of data, the NDAA man-
dated the creation of the Healthcare Team
Coordination Program (HCTCP).
Specifically, the NDAA requires:

The creation of a Healthcare Team
Coordination Program (HCTCP) which
will be integrated into all DoD health-
care operations.

The establishment of two Centers of
Excellence (COEs) for the develop-
ment, validation, proliferation, and
sustainment of the HCTCP.

Expanding the focus of the HCTCP
from the emergency care environment
to include all major medical special-
ties.

Continuing research and development
investments to improve communica-
tion, coordination, and teamwork in
the provision of healthcare.
JCAHO has also made patient safety a top
priority. They have developed a new
approach to standards which focuses on
patient safety and the incorporation of
“methods of team training to foster an
F0011 2004
Page 3 Reporting Near Misses
Page 4 Human Factors Intro
Page 5 MTT Quiz
Page 6 FDA Bar Code Rule
interdisciplinary, collaborative approach to
the delivery of patient care”. Currently,
three of the seven National Patient Safety
Goals align with requirements for team
training and improved communication.
Also, in reviewing the proposed 2005
National Patient Safety Goals, it is apparent
that communication will continue to be a
critical component of the patient safety
goals.
Crew Resource Management
Poor teamwork and a lack of communica-
tion cause catastrophic mistakes in a wide
array of settings. In particular, the aviation
field recognized several decades ago that
“human errors” caused approximately 70%
of flight mishaps. To minimize errors,
flight crews began receiving Crew Resource
Management (CRM) training in the 1970s.
CRM teaches flyers the principles of team-
work, communication, stress management
and other human factor principles to pre-
vent aviation mishaps. It has been noted
that physicians and pilots have important
similarities. Individuals in both groups
have extensive technical training and view
themselves as the final authority. They con-
sider themselves to be self-sufficient and
independent, but are increasingly forced to
rely on newer, more complicated technolo-
gies and additional staff to accomplish their
missions. To prevent medical errors, the
DoD adapted the skills and behaviors of
CRM for use in the Military Health System
(MHS).
Continued on page 2
PATIENT SAFETY
MANAGERS AS
TEAMWORK
CHAMPIONS
Review of DoD Team Training
continued from page 1
What is Medical Team Training?
MTT is a set of teachable, learnable team-
work skills and behaviors. Taught and
practiced in an interactive class environ-
ment, these skills and behaviors are then
reinforced on a daily basis in the work set-
ting until they become part of the culture.
Some examples are listed below:
Team Structure delineates the funda-
mentals of teams such as size, mem-
bership, and leadership. Teamwork
cannot occur in the absence of a
clearly defined team. Upon forma-
tion of the team, the leader
defines the roles and responsibili-
ties of each of the team members.
Situation Awareness involves all
team members having a sense of
what’s going on around them at all
times. This assists in the preven-
tion of medical errors through the
sharing of important information
among team members. All team
members are responsible for
maintaining their own situation
awareness.
Shared Mental Model is a men-
tal picture of all the relevant facts
and relationships that define an
event, situation, or problem. This
mental picture or model is shared
by team members so that everyone
on the team can be “on the same
page”. Shared mental models are
reinforced through the processes
of planning, team decision-mak-
ing, and communicating informa-
tion. The model is maintained
through situation awareness and
on-going communication. Team
briefings at the beginning of the
shift or case foster a shared men-
tal model among team members.
Advocacy and Assertion is an
intervention utilized when a team
CAPT John Webster, Naval Medical Center San Diego teaches the team training course at
Naval Hospital Rota, April 14, 2004.
member’s viewpoint doesn’t coin-
cide with that of another team
member or the team leader. It
involves speaking up in a respect-
ful way to question a decision or
action. Failure to speak up has
been identified as a primary con-
tributor to clinical errors.
Two-Challenge (Attempt) Rule
is an intervention used when
“speaking up” does not get a
response, or the response is not
satisfactory. All team members
are responsible for bringing up
their concerns at least two times
to ensure that they have been
heard. The “challenged” team
member is responsible for
responding back to acknowledge
that the concern was heard, and to
explain the rationale if time and
circumstances permit. If the chal-
lenger is still not comfortable with
the decision, he/she is expected to
utilize the chain of command.
Check Back (Readback) is a
technique for information verifica-
tion. Whenever a verbal order is
given, a verification “readback” of
the complete order by the person
receiving the order is conducted.
Brief/DeBrief Briefings are short
meetings of the team (3-5 min-
utes) that are held at the begin-
ning of a shift or OR case to help
maintain situation awareness and
2
shared mental models. Sometimes
called “team huddles”, they
include the entire team. Debriefs
are held after events, shifts, or OR
cases to allow the team an oppor-
tunity to evaluate their teamwork
and make improvements. These,
too, are short meetings (1-3 min-
utes).
Sterile Team Environment is a
teamwork technique used during the
high-risk phase of a procedure or
work duty (i.e. times requiring undi-
vided attention). Distractions are min-
imized in the environment to ensure
safety for patients and staff. Team
members are expected to communi-
cate to the team if something is dis-
tracting them.
Continued on page 5
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.
NEWS FROM THE
PATIENT SAFETY
CENTER
Feedback and Suggestions
Based on Your Reporting
NEAR MISS REPORT-
ING IMPROVES
PATIENT SAFETY
Data From 2003 Reports
By: Mary Ann Davis, RN, BSN, MSA
Nurse Risk Manager, Patient Safety
Center
I dentifying near misses remains an
essential part of the DoD Patient
Safety Program (PSP). A near miss as
defined by the PSP is "any variation or
error that could have resulted in harm
to a patient, visitor, or staff, but through
chance or timely intervention did not
reach the individual ". MTFs are
encouraged to submit an example of a
near miss for review by
the Patient Safety Center
Registry (PSR) with each
Monthly Summary Report
(MSR). The Patient Safety
Center (PSC) uses these
reports to identify lessons
learned and to verify that
Patient Safety Managers
understand the definition
of a near miss. Not only
are facilities reporting
more near misses, the
accuracy of near miss
reporting appears to be
rising as well. The PSC expects that the
number of near miss reports will con-
tinue to increase as near miss reporting
continues to be emphasized.
Most Monthly Summary Reports contain
at least one near miss event and, of
these, most included a narrative
description. These near miss narratives
reveal both weaknesses in the system
and recovery processes which, when
identified and implemented, assure a
safer environment. Near miss narra-
tives are reviewed for trends of poten-
tial patient safety errors and areas that
need further investigation. Examples of
near misses are also submitted to the
PSR in MEDMARXSM. Most medication
errors reported in FY03 were near
misses while most non-medication
events reported were no harm events
(events reached the patient but did no
harm).
The PSC reviews near miss examples for
lessons learned and action(s) taken to
prevent possible future events. Insight
gained from these near misses may lead
to system-wide interventions, and the
information is fed back to MTFs.
Reports, properly de-identified, are also
shared with other patient safety pro-
grams. For example, look-alike issues
with medications, such as occur with
similar appearing nebulizer packages
(see below), are forwarded to the
Institute of Safe Medication Practice.
The near miss narrative section of the
Monthly Summary Reports gives the
Patient Safety Center a window into the
safety events occurring within the MTFs.
By regularly submitting near miss nar-
ratives to the PSR the system's weak-
nesses and recovery processes can be
shared with other MTFs and a safer mil-
itary health system can be created.
3
Patient Safety Links
Interesting Resources To Explore
QualityHealthCare.org
www.qualityhealthcare.org
“Streamlining the Office Practice: Naval
Hospital Pensacola”
http://www.qualityhealthcare.org/ihi/Topics/
OfficePractices/Access/ImprovementStories/
StreamliningtheOfficePracticeNavalHospital
Pensacola.htm
Naval Hospital Pensacola improvements in
patient access as member of IHI’s Impact
network.
Institute for Healthcare Improvement
www.ihi.org
“What’s New”: Cover Story from the Boston
Globe Magazine
A highly readable, personal profile of Don
Berwick, CEO of IHI and one of most innova-
tive thinkers in patient safety today.
Institute of Medicine
www.iom.edu/report.asp?id=19723
Health Literacy: A Prescription to End
Confusion
New IOM report suggests that nearly half of
all American adults have limited health liter-
acy leading to increased costs and
decreased quality; outlines need for coordi-
nated improvement efforts.
Consumers Advancing Patient Safety
www.patientsafety.org
A national, consumer-led non-profit organiza-
tion formed to be a collective voice for
those who suffer harm in healthcare
encounters. Just published report submitted
to AHRQ contains action plan and six nation-
al goals related to healthcare and judicial
reforms.
“Defining the Patient-Physician Relationship
for the 21st Century”
www.patient-physician.com
Consensus report on improving the interac-
tion between physician and patient devel-
oped at the Third Annual Physicians Meeting
and Johns Hopkins Outcomes Summit in Nov.
2003.
National Patient Safety Foundation
www.npsf.org
“Focus on Patient Safety” - Vol. 7, Issue 1,
2004. Newsletter contains interesting arti-
cle on move to link revenue to performance
in hospital reimbursements.
Institute for Safe Medication Practices (ISMP)
www.ismp.org/NursingArticles/index.htm.
Nurse Advise-Err - peer reviewed, medication
safety newsletter written especially for
INTRODUCTION TO
HUMAN FACTORS
Making Systems Work for Safety
by Bridget Olson
Human Systems Engineer, Patient Safety Center
H uman factors, a familiar “buzz-
word” in patient safety, stated
most simply is about designing the sys-
tem for the user, instead of fitting the
user to the system.
The Department of Defense (DoD) has
standard definitions for familiar human
factors terms that can be used as a
starting block in understanding human
factors1:
Human Factors - A body of scientific
facts about human characteristics;
includes, but is not limited to, principles
and applications in the areas of human
engineering, personnel selection, train-
ing, life support, job performance aids,
and human performance evaluation.
Human Engineering- The application
of knowledge about human capabilities
and limitations to system or equipment
design and development to achieve effi-
cient, effective, and safe system perform-
ance at minimum cost and manpower,
skill, and training demands.
System - A composite of equipment,
skills, and techniques capable of per-
forming or supporting an operational
role, or both. A complete system
includes all equipment, related facilities,
material, software, services, and person-
nel required for its operation and sup-
port to the degree that it can be a self-
sufficient unit in its intended operational
environment.
During World War II, as new machines
were developed for the war and the com-
plexity of manned systems grew, the field
of human factors emerged. Human fac-
tors began to branch out into the space
program and other industries as the
importance of improving human/
machine performance and systems
analysis was recognized. The study of
human factors has been an important
part of ensuring safety in the aviation
industry and learning from serious dis-
asters.
Although it has become more prominent
in recent years, the field of human fac-
tors was researched in the health care
arena as early as 1970. Health care is
slowly embracing human factors as a
tool to reduce errors through under-
standing health care systems. Human
factors has been applied to increase the
safety of medical tools, devices and
equipment and to improve the processes
and procedures utilized within the med-
ical system.
Human factors is challenging to apply
because our familiar routines become
an ingrained part of our performance.
We often follow them without thinking
because they are based on the concept
that “this is how it is always done”. They
often include “work arounds” which we
invent to adjust to system problems and
avoid system failures. We understand
our work as individuals easily, but we
have more difficulty seeing our place in
the whole system. The application of
human factors challenges every one of
us in health care to think about all the
pieces of our particular system. It is an
important tool in our on-going efforts to
prevent errors. By understanding
human factors we can better understand
our roles as critical problem solvers in a
complex system. This is the practical
effect and immense value of human fac-
tors in our day-to-day patient care
efforts.
In practice, the use of a macroergonom-
ics approach to human factors applica-
tion requires us to consider all of the
pieces of our system and their interac-
tions with each other. If we don’t consid-
er these factors, we can not determine
4
their effects on our systems.
If each of us enlarges our understand-
ing of our daily processes to include the
human factors perspective, we can
improve the effectiveness, efficiency,
and the SAFETY of our systems.
Consideration of the human factors
issues involved with any practice initia-
tive will also encourage user acceptance
and increase job satisfaction, comfort,
and quality of life within our systems.
Most importantly, taking this proactive
approach to finding systems issues can
prevent harmful events from occurring.
“News From the Patient Safety Center”
will continue to highlight specific
human factors and related practice con-
siderations in upcoming issues of the
Newsletter. In the meantime, if you are
interested in additional human factors
information, you should read
“Improving Patient Safety By
Incorporating Human Factors” at
http://qualityhealthcare.org/ihi/Topics/P
atientSafety/MedicationsSystems/Literatu
re/ImprovingPatientSafetyByIncorporati
ngHumanFactors.htm. This comprehen-
sive article provides further introducto-
ry material and practical suggestions
based on the experience of the Iowa
Health System. For a more in depth
introduction to human factors and an
alternative work system model, you can
access the Human Factors Awareness
Web Course, developed by the Federal
Aviation Administration at
http://www.hf.faa.gov/Webtraining/index
.htm.
1
Department of Defense. Department
of Defense Handbook – Definitions of
Human Factors Terms. 16 August
1999. Mil-Hdbk-1908b
Sanders, M.S., McCormick, E.J.,
Human Factors in Engineering and
Design. McGraw-Hill, Inc. New York,
1993.
PATIENT
SAFETY IN
ACTION
Experiences and Suggestions
From the Field
continued from page 2
Where in the MHS has MTT
been implemented?
Many MTFs and combat units have imple-
mented team training. Recent champions
and success stories include:

Army
The Army Trauma Training Center
(ATTC) provides clinical and team-
work skills training for active duty and
reserve forward surgical teams (FSTs)
preparing for deployment to Iraq and
Afghanistan. Effective teamwork has
been identified as a crucial element in
providing fast, life-saving trauma care
to soldiers on the battlefield. The ATTC
has recently revised their curriculum
to incorporate and emphasize team-
work skills and behaviors. In addition
to providing didactic content about
teamwork, the faculty is coaching FST
members in the use of teamwork
throughout their clinical rotations and
combat trauma simulation exercises.

Navy
Navy Medical Center San Diego
(NMCSD) Main Operating Room
(MOR) consisting of eighteen surgical
suites, is the first to have implemented
a teamwork system. Their success in
training more than 75% of the 900
employees who comprise the Surgical
Services Directorate (DSS) has led to
receiving the 2003 DoD Patient Safety
Award for Teamwork. The staff also
created an innovative evaluation tool
called a “huddle card” for use during
team debriefings. These small, pocket-
sized cards are completed by the team
at the conclusion of surgical cases.
They assist the teams in evaluating
their teamwork performance and give
them a tool that can measure their
improvement over time. The cards
now serve as a prototype for staff in a
wide variety of military medical set-
tings.

Air Force
centers. Taking a different approach,
the orthopedic service at the 96th
In general, over the last year, the Air Medical Group at Eglin AFB, FL, effect-
Force trained 56 instructors to contin- ed change by grouping complex cases
ue facilitated team training efforts in to increase team member proficiency
the MTFs. The Air Force Materiel
Command and Air Education and
for non-routine surgeries. Surgeons
relate increased competency with
Training Command, both staunch back-to-back-to-back cases and
advocates for medical team training, decreased frustration.
hosted the training sessions. Because
of leadership engagement in patient What is the role of the PSM?
safety and team training endeavors, Effective team building takes time and
team training is beginning to effect effort. Sustainment is crucial and your sup-
changes in culture and practice. One port is needed. You can:
such example is from the 82 nd
Work with your leadership to embrace
the team approach
Medical Group at Sheppard AFB, TX,

Take the lead and be a champion for
where team training was integrated as
team intervention at your facility
a part of newcomer’s orientation for
Get staff involved in the HCTCP
all staff members. In addition, over Remember, medical team training is an
800 staff members received an intro- organizational tool to effect change and fur-
duction to team training and are cre- ther promote a culture of safety.
atively using the tools in their work-
To learn more about teamwork training or receive consultation on how to
bring teamwork training to your facility, contact the following individuals:
Heidi Deputy Director Patient 703-681-0064 Heidi.King@tma.osd.mil
King Safety Program/Manager x3611
Healthcare Team
Renée Patient Safety Senior 703-681-0064 Renée-claire.norris@tma.osd.mil
Norris Program Analyst x3621
Lauren Patient Safety Senior 703-681-0064 Lauren.Toomey@tma.osd.mil
Toomey Program Analyst x3686
Medical Team Training Quiz
Can your facility benefit from Medical Team Training?
Answering “true” to one or more of these statements indicates that your facility will
benefit from using more teamwork principles.
1. When a lot of work needs to be done quickly, staff members don’t work as well
together as they could.
2. Staff members don’t always speak up if they see something that may negatively
affect patient care.
3. Hospital departments do not coordinate well with each other.
4. We have patient safety problems in this unit/hospital.
5. Things “fall between the cracks” when transferring patients from one unit to another.
6. When adverse events have occurred, it has not always been easy to determine who
was in the role of Designated Leader.
7. Important patient care information is often lost during shift changes.
8. Staff members are afraid to ask questions when something does not seem right.
9. There have been instances where actual or potential mishaps could have been pre-
vented if lessons had been learned from previous mistakes.
10. There have been instances where routine medical procedures went wrong because
of inadequate preparation beforehand.
5
BAR CODE
LABELS
REQUIRED
FDA Issues Regulations
R esponding to the need to reduce
medication errors, the Food and
Drug Administration, on February 25,
2004, finalized a rule requiring bar
codes on most prescription drugs and
on certain over-the-counter drugs. The
rule also requires machine-readable
information on container labels of blood
and blood components for use in trans-
fusions.
The rule is designed to encourage hospi-
tals to adopt advanced information sys-
tems which scan patient and drug bar
codes, and compare and verify that the
correct patient is receiving the correct
drug and dosage at the proper time.
HHS Secretary Tommy G. Thompson
explained that: “Bar codes can help
doctors, nurses and hospitals make sure
that they give their patients the right
drugs at the appropriate dosage. By giv-
ing health-care providers a way to check
medications and dosages quickly, we
create an opportunity to reduce the risks
of medication errors that can seriously
harm patients”. (FDA Press Release, Feb.
25, 2004).
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.
CONFERENCE
The FDA estimates that the use of bar
codes will help prevent nearly 500,000
adverse events over 20 years and will CALENDAR
lead to significant cost savings by reduc-
ing extended stays due to errors and DOD CENTER FOR EDUCATION
lessening medication error related litiga- AND RESEARCH IN PATIENT
tion and malpractice costs. Veterans
Affairs hospitals have been using bar
SAFETY (CERPS)
ENHANCED TRAINING FOR
PATIENT SAFETY MANAGERS
codes for medication administration
since June 2000 and have reported that June 7-11, 2004, June 21-25, 2004
medication error rates have been July 12-16, 2004, July 19-23, 2004
reduced by as much as 86.2% in some August 2-6, 2004, August 16-20, 2004
hospitals. For more information on this Bethesda, Rockville, Maryland area
important regulation see the April 14, http://patientsafety.ha.osd.mil
2004 issue of JAMA (Vol. 291, No. 14),
or access the FDA website directly at: ANNUAL NATIONAL FORUM ON
http://www.fda.gov/oc/initiatives/bar- QUALITY IMPROVEMENT IN
code-sadr/ . HEALTH CARE
December 12-15, 2004
Orlando, Florida
www.ihi.org
Patient
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
on the progress of the DoD Patient Safety Program.
DoD Patient Safety Program
Office of the Assistant Secretary of Defense (Health Affairs)
TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, Virginia 22041
703-681-0064
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