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

INSIDE: DoD Continues to Expand Patient Safety Initiatives

FALL 2008

PSC Focus on Falls4 TeamSTEPPS Update8National Healthcare Safety Network3

Second Cycle Results Show Positive Trend

DoD 2008 TRI-SERVICE SURVEY ON PATIENT SAFETY

The DoD Tri-Service Survey on

Patient Safety is an anonymous websurvey designed to assess staff opin-

ions about issues related to patient safety in

the Military Treatment Facilities (MTFs)(Figure 1). All staff working in Army, Navy,

and Air Force Military Treatment Facilitiesand dental treatment facilities world-wide

were asked to complete the survey. Thissurvey was first conducted in late2005/early 2006 and was conducted for a

second time in Spring 2008.

The purpose of the survey is to:

Understand the current status of patientsafety culture in MTFs

Raise staff awareness about patient safety

issues Assess trends in staff attitudes

Develop an action plan to continue to pro-vide a safer care environment in all MTFs

ResultsThe DoD Patient Safety Program is very

enthusiastic about the 2008 culture surveyresults. They affirm the positive direction in

which patient safety continues to advance inthe MTF. The success of the survey depends

upon utilizing the results to help focus on

areas that may need greater attention whilemaintaining our identified strengths.

ParticipationThe overall 2008 MTF and Service levelparticipation as measured by response

rates were higher than the first surveyadministration. Of all MTF staff across all

facilities world-wide, 70,817 participatedyielding a 5% response increase over thefirst administration (Table 1). Results

represent 465 facilities including 60 hos-pitals, 331 clinics, and 74 dental clinics.

Respondents self-reported demographics(years worked in facility, years of current

special ty experience, staff type, etc)remained fairly consistent across the twosurvey administrations. As well, the same

percentage of respondents (71%) report-ed direct interaction with patients. Since

the population demographics remain

consistent, it is appropriate to draw com

parisons between survey periods.

Table 1: Response Rate

2005/2006 2008

MTFs 53% 58%

Trending ResultsRespondents were asked to Grade theiwork area (Figure 2). The large majority

graded their work area as A-Excellent orB-Very Good (81%). Fewer (15%) gav

their work area a C-Acceptable than inthe first survey. Both results signal a posi

tive movement.

Across the patient safety dimension areasthe MTFs increased from 1% to 3% on 10of the 12 patient safety culture areas

Figure 1:Patient Safety Culture Survey Areas

Twelve Dimensions Overall perceptions of patient safety Management support for patient safety Supervisor/manager expectations &

actions promoting patient safety Non-punitive response to error Frequency of events reported Organizational learning-Continuous

improvement Communication openness Feedback and communication about

error Teamwork within work areas Teamwork across work areas

Handoffs and transitions Staffing

Other Items Captured Patient safety Grade in work area Number of events reported in the

past year Opportunity to provide open-ended

comments

Figure 2:MTF Trending by Patient Safety Grade

2005/2006 2008

MTF Trending Results for Number of Events Reported

Percentof

Respondents 60

40

20

0A B C D E

Excellent Very Good Acceptable Poor Failing

Patient Safety Grade

* MTF Strength

Article continued on page 2


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2 FALL 2008 PATIENT SAFETY

Army, Navy and Air Force In-Patient Facilities are members of the Stand Up for Patient Safety programsponsored by the National Patient Safety Foundation (NPSF). Launched in 2002 by sixteen foundingmembers, it has grown to include over 400 healthcare organizations. The Program provides a mean-ingful way for organizations to participate in the patient safety movement and demonstrates a commit-ment to patient safety both within the participating organizations and among their communities. Mem-ber organizations receive timely and important information on patient safety implementation strategies.They may also access an array of practical tools to facilitate the incorporation of patient safety into thehospital culture and enhance existing safety and quality programs, including interactive audio and web-based forums designed to share best practices. For more information about program particulars, pleasevisit www.npsf.org.

remained the same on two, and did notdecrease on any (Table 2). Nine of the

twelve areas received a 60% or better posi-tive response with only three areas fallingbelow 60%.

Table 2: MTF Trending Results by PatientSafety Culture Area (Dimension)

The same patient safety culture areas thatemerged as areas of strength and areas for

improvement in 2005/2006 also emerged in2008 (Figure 3). It should be noted that each

of these areas have improved by 1-2%. Theareas identified as strengths or opportunities

are not surprising and remain consistentwith results from the more than 500 civilian

hospitals, which comprise the Agency forHealthcare Research and Quality (AHRQ)snational patient safety culture survey bench-

mark database.

The perception question onFrequency ofEvents Reported yielded the largest increase

between surveys (Table 2). While the MTFs

increased the most in this area, it is not yet

an area of strength. Seventy-three percent ofrespondents indicated that they reported no

events in the past twelve months, as meas-ured by the single item question:Number of

Events Reported. This has been identifi

an area for improvement (Figure 4).

The forthcoming release of the Patient ty Reporting System is expected to posi

impact both of these surveyed areas.

Next Steps

ReportsEach MTF will receive a report summarits results. Where appropriate, reports

include comparisons within a Service, athe MTFs, trended with the 2005/06 sudata, and benchmarked to AHRQs nat

database of civilian hospital patient sculture survey results. To access your f

tys report, please contact your SePatient Safety Representative.

Action PlanningOverall, the results represent a conti

patient safety focus. While some opportareas remain for the MTFs, those may v

the local level. It is important to delveyour facility level details to understand w

interventions will most effectively imyour facility. Technical assistance confecalls are scheduled for each Service. The

are designed to help you interpret and your facilitys results. Contact your S

Patient Safety Representative for more don the calls. Additionally, AHRQ sponso

National User Group Meeting, Decembefor patient safety culture survey users to

from and network with others. Cwww.ahrq.govfor more details.

For other questions or comments onpatient safety culture survey, please co

Mr. Michael Datena, Program AnDoD Patient Safety Program,

[email protected].

Figure 4: MTF Trending for Number ofEvents Reported

2005/2006 2008

MTF Trending Results for Number of Events Reported

PercentofRes

pondents 80

60

40

20

0None 1 to 2 3 to 5 6 to 10 11 to 20 21 or more

Number of Events Reported in the Past 12 Months

* MTF Area for Improvement

Patient Safety Culture Area Di fference Change

1. Overall Perceptions of Patient Safety +1 2. Frequency of Events Reported +3 3. Supervisor/Manager Expectations &

Actions Promoting Patient Safety+1

4. Organizational Learning Continuous Improvement

+2

5. Teamwork Within Work Areas +1 6. Communication Openness 0

7. Feedback and CommunicationAbout Error

0

8. Nonpunitive Response to Error +1

9. Staffing +1 10. Management Support for Patient

Safety+2

11. Team work Across Work Areas +1 12. Handoffs and Transitions +2

Figure 3:Strengths and Opportunities

Strengths Teamwork with work areas Supervisor/manager expectations and

actions promoting patient safety Management support for patient safety

Improvement Opportunities Handoffs and transitions Staffing Non-punitive response to error

Areas of strength and opportunitymatch results from 500+ civilianhospitals.

Each of the strengths and opportunityareas improved from 2005/06 results.

Article continued from page 1

TRI-SERVICE SURVEY


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PATIENT SAFETY FALL 2008 3

DoD FACILITIES PARTICIPATE IN CENTERS FOR DISEASE CONTROL AND

PREVENTION (CDC) NATIONAL HEALTHCARE SAFETY NETWORK (NHSN)The Clinical Proponency Steering Commit-

ee (CPSC) in October 2007 approved DoDarticipation in the National Healthcareafety Network (NHSN), the web-based

national Healthcare Acquired InfectionsHAI) surveillance system administered by

he Centers for Disease Control (CDC). Thisdecision was meant to improve the visibility

f infection control efforts at the MHS andervice levels, which traditionally had been

ocal MTF functions.

The NHSN provides a nationally recognized,

eady-made infrastructure for reporting, eval-uating and comparing infection-related data.

ts use also ensures adoption of standard def-nitions for device-related, procedure-relatednd antimicrobial resistance trends. Over the

ast year the number of US hospitals usingNHSN has grown dramatically.

In March 2008 a data use agreement between

CDC and DoD was signed, and an imple-mentation and training plan was distributedto Service Headquarters Quality Depart-

ments. Initial milestones for implementationwere set. Service Infection Preventionist (IP)

Champions were named. TMA Quality andPatient Safety Program Offices facilitated a

two day NHSN workgroup in August. TheWorkshop brought together Service Quality,IP Champions, and Service selected facility

IPs to focus on Service and DoD efforts touse NHSN to report, aggregate and analyze

HAI data and to clarify areas of activityrequiring additional work.

Initial operating capability sites (IOCs) havebeen selected for each Service. Based on dis-

cussions with CDC, the workgroup hasdetermined that DoD will focus initially on

the Device Associated Module of NHSN and

report data on two of the three componentof the module: Central Line Blood Stream Infections

Ventilator Associated Pneumonias

A second workgroup meeting is planned foJanuary 2009 as group activities transition to

the MHS Clinical Quality Forum (CQF)Infection Prevention and Control PanelMajor topics for the January meeting

include: Lessons learned from the IOC sites

Rightsizing -- additional MTFs to reporHAI data in NHSN

Determining how NHSN modules will bchosen for inclusion Leadership interest

Facility Risk Assessment IP training and qualifications

The Department of Defense (DoD) Patientafety Program (PSP) has funded three

ourses designed to continue improving theafety and quality of obstetrics care provided

n our MTFs. The objective is to offer a stan-dardized set of clinical courses for all MHS

maternal newborn providers and nursingersonnel involved in obstetric care, includ-

ng those in training programs. These cours-

s augment existing Service-specific trainingnd competency programs. The courses are:

Web-based introductory fetal heartmonitoring

Classroom-based perinatal nursingeducationClassroom-based neonatal nursing

education

The Joint Commission cites perinatal deathsnd/or loss of function among the top ten

most frequently reported sentinel events.The number of perinatal sentinel events in

ur system remains very low relative to the

extent of services provided, a testament toour perinatal care quality. However perina-

tal sentinel events rank in the top five high-est reported sentinel event categories. The

DoD Patient Safety Center reports inade-quate training as a causal factor in 44% of

perinatal sentinel event root cause analyses.Perinatal care is among the most commonreasons for hospital admissions in the MHS.

Based on these findings it is clear that oppor-tunities for improvement exist.

To address those opportunities, a Tri-Service

perinatal workgroup, comprised of perinataland maternal-child health consultants, con-vened in September 2007 to select course

options and plan a coordinated implementa-tion. By September 2008, over 1,800 multi-

disciplinary staff members had completed theweb-based introduction to fetal heart moni-

toring. Over 600 nurses are participating in theperinatal and neonatal education classroom-based courses. The Tri-Service perinatal work-

group continues to collaborate informallywhile the DoD PSP serves as a facilitator, sup

porting the Workgroups plans.

The Services will need to actively engage theMTFs in the continued use of these educa

tional tools. Clinical champions and leadership support, at the Service and MTF levelsare essential for course participation and

course competency sustainment. Please contact your Service point of contact (POC

below for more details on the courses, andfor information on participation guideline

and access to DoD funded continuing edu-cation credit for nurses and physicians.

Air Force: Maj Karin Van [email protected]

Army: LTC Mary Katherine [email protected]

Navy: CDR Khin [email protected]

PSP Funds Standardized Clinical Curriculum

OBSTETRIC-RELATED EDUCATION COURSES NOW AVAILABLE

Opportunities For the FieldPATIENT SAFETY PROGRAM INITIATIVES

The Patient Safety Program is pleased to share the following updates onsystem-wide initiatives that resonate across the entire scope of the MHS patient safety efforts.


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Crash!!! An anxious voice yells helpme. You rush to the room and dis-cover a patient on the floor, her feet

tangled in the tubing from her Foleycatheter. A patient has fallen on your unit.

Patient falls are a perennial occurrence in

healthcare settings. Consequences can bedeadly for the patient and upsetting anddemoralizing for staff. Regardless of who

falls, the event has serious repercussions forall individuals involved.

According to The Joint Commission,

approximately 6.1% of reported Root CauseAnalyses (RCAs) involve patient falls.1 In2005 the Commission published National

Patient Safety Goal (NPSG) # 9Reduce therisk of patient harm resulting from falls.

Goal #9 includes the following elements: Assess and periodically reassess each

patients risk for falling. Include the potential risk associated with

the patients medication regimen. Take action to address any identified risks. Implement a fall reduction program and

evaluate the effectiveness of the program(2006).

Facilities are now in the second year of having

implemented a comprehensive fall reductionprogram. How effective and efficient is yourprogram? Audrey Nelson, PhD, RN, FAAN,

director of the VA Patient Safety Center ofInquiry, Tampa, Florida suggests that the

healthcare industry has not cracked the codefor patient falls for the following reasons2:

Lack of standardized definition of fall.Within DoD there is no standard taxonomy

for falls. Facilities are encouraged to developa definition. This will enable the staff to

objectively determine when a fall occursand how to initiate your fall reduction pro-

gram from reporting to intervention. Failure to differentiate type of fall. Janice

Morse, PhD, RN classifies falls into three

categories: Accidental; Anticipated Physio-logical; and Unanticipated.3 According to

Nelson, facilities should direct theirresources to address prevention/reduction

initiatives in the Accidental and Anticipat-ed Physiological categories because patient

falls in these categories can be anticipatedand prevented.

Failure to differentiate between fall screen-

ing and fall risk assessment. Nelson sug-gests that staff need to be trained to under-

stand that using the tool to determinepatient risk for falls is only a screening that

leads to a full risk assessment. Failure to link fall risk assessment to spe-

cific interventions. Once the patient is

identified as being at risk for falls becauseof an identified criterion, interventions

must be implemented to prevent the fall. Failure to differentiate fall prevention and

fall protection. Nelson notes that despitethe best efforts, all patient falls may not beprevented. She stresses that the ultimate

goal is to prevent physical injury. For exam-ple, with frequent fallers from bed, a strate-

gy for minimizing injury may include plac-ing the bed in a low position and padding

the surrounding area with mats. Failure to adjust for fall-related risk. Too

often facilities only consider the decrease in

numbers of fall reports as an indicationa units fall program is successful. N

suggests that a unit that has a larger nuof patients at risk should have its thre

for falls adjusted accordingly, as it conably may experience a higher fall frequ

Blame the nurse mentality. Nestresses this mentality is lethal to thecess of a program. Programs sh

embrace the multidisciplinary approSuggestions include developing a

process for managing and monitorinpatient which fosters a joint effort at k

ing patients safe and diminishes the fon a single individual care giver.

Evaluating and strengthening a patienreduction program is a continuous

methodical process. Consider your links. They may involve the prog

design, patient/staff education, and comance. A strong program identifies tindividuals who are at greater risk

falling and sustaining injuries, and etively identifies at risk patients throug

fall-screening process. An even stroprogram identifies the specific fall risk

challenges the patient and customizes iventions that prevent or mitigate a fallthe resulting injury.

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

Fine Tuning Your Program

PATIENT FALLREDUCTION

Pamela Copeland, JD, RN, BSNPatient Safety Analyst

Fall simulation photo, provided by the DoD Patient Safety Center (PSC), used as parthe PSP fall education efforts.


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The Joint Commission requires facilities toeriodically re-evaluate their patient fall pro-rams. The suggestions above will help you

crack the codeat your facility and transform

our fall prevention program into an effective,fficient, and dynamic process that ensureshe safety of the patients in your care who are

t the greatest risk for falls and injury.

Recent Joint Commission Survey FindingsPSC Wants to Hear From You

The triennial Joint Commission survey

rocess often engenders anxiety. The survey-rs are trained to identify every opportunity

or the facility to improve quality and safetyrocesses. Is your patient fall program ableo withstand The Joint Commission muster?

During FY 2008 a DoD facility had its trien-

nial review. This facility is a robust hospitalwith affiliated clinics. Reportedly, the sur-

eyor asked about the patient fall program.The patient safety manager presented thedocumentation that demonstrated the full

cope of the program policies, fall rate,nd the reporting tool. The surveyor subse-

quently asked, How do you identify, man-ge, and monitor patients in the ambulato-

y area for falls? The patient safety manag-r had no response.

Shortly after the survey, the patient safetymanager convened a multidisciplinary teamto address this issue. With any deficiency

you take the hit and move on. We took the

surveyors recommendations and incorpo-rated them into our patient fall program.

Some recommendations included: Add a criterion to identify patients over 65

years of age.

Include a fall severity score. Include post-surgical patients.

The Joint Commission surveyor findings

exceeded the literal requirement of NPSG#9.Nonetheless, the facility concluded that thesurveyors suggestion promoted patient safe-

ty fall reduction activity across their health-care continuum in the hospital, as well as

the ambulatory setting. The involved facilityshared valuable information that may bene-

fit other MTFs undergoing triennial surveys.

The PSC is partnering with MTFs (Tri-Ser-

vice) to develop an ambulatory fall reduc-tion policy that may be used by the field.

This work group, the National Capital AreaAmbulatory Patient Fall Reduction Commit-

tee, had its inaugural meeting on 27 October,2008. Work group members are:

Walter Reed Army Medical Center National Naval Medical Center Wright-Patterson Medical Center

Dewitt Health Care Network

Malcolm Grow Medical Center Kimbrough Ambulatory Care Annapolis Naval Medical Clinic

Naval Medical Clinic, Pax River

Does your facility have a formal process to

address patient falls in the ambulatory setting? If you do, please forward your SOPs to

the PSC: [email protected]. Letspread the gain using our mutual experi-

ences and talents to enhance patient safetywithin the DoD.

References

1. The Joint Commission Sentinel Event Statis

tics as of: September 30, 2008. http://www

jointcommission.org/NR/rdonlyres/241CD6

F3-6EF0-4E9C-90AD-7FEAE5EDCEA5/

0/SE_Stats9_08.pdf Accessed: 23 October

2008.

2. Nelson, A. Cracking the Code for Patien

Falls. 9th Annual Transforming Fall Preven

tion Practice. Clearwater, Florida, 2009.

3. Morse, J. (1997) Preventing Patient Falls

Thousand Oaks, California: Sage.


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

PSC WELCOMES SUSAN FREEBURNNurse Patient Safety Manager

Mary Ann Davis, Nurse Patient Safety Manager, has left the Patient Safety

Center (PSC), to take a position at Fort Myers as an Occupation Health

Nurse. Everyone at the PSC will miss Mary Anns wisdom and cheerful per-

sonality. We are pleased, however, to welcome Susan Freeburn as our new

Nurse Patient Safety Manager. This is something of a homecoming for Susan,

who last year left the Office of Legal Medicine, which shares office space with

us, to take a position as a Nurse Patient Safety Specialist at the National

Naval Medical Center in Bethesda.

Susan brings a varied background of expertise to her new position here at

the PSC. Prior to her tenure with the Office of Legal Medicine, Susans career

included positions in Quality Assurance, Risk Management, and Utilization

Review. During her six months at Bethesda, she conducted an FMEA and

was an active advisor in the roll-out of the Hand Hygiene Initiative, includ-

ing scripting the new Hand Hygiene video which will be distributed through-

out the DoD. Susans main concentration was on patient safety events report-

ed to the Patient Safety Office. She responded to trends in behavior and

mishaps with SBAR communication tools.

Susan also spearheaded the Patient Safety Committee at Bethesda, which

met weekly. This multi-disciplinary group of physicians from all specialties,

pharmacy, ITD, legal counsel, and nurse executives reviewed serious cases

not identified as sentinel events, but deemed worthy of an investigation to

determine standard of care and processes that failed. They issued actionable

items with a point of contact and due date for remediation and follow-up

with the committee.

Susan brings many skills to her new role at the PSC. As we welcome her to

the PSC, we are pleased to introduce her to the many MTF Patient Safety

Managers with whom she will be working. Susans contact information is:

[email protected]


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MTFs and AHRQ: PARTNERS IN IMPLEMENTING PATIENT SAFETYMTFs Contract to Adapt PIPS Projects

The Agency for Healthcare Researchand Quality (AHRQ) has contractedwith three Military Treatment Facili-

ties (MTFs) to adapt Partnerships in Imple-menting Patient Safety (PIPS) projects. CarlR. Darnall Army Medical Center, Fort

Hood, Texas; Madigan Army Medical Cen-

ter, Fort Lewis, Washington; and the NavalMedical Center San Diego, San Diego, Cali-fornia will be active participants in a pro-

gram, led by AHRQ, to share and implementsafe practice interventions to improvepatient safety.

The AHRQ PIPS program is a direct out-

growth of the larger AHRQ Patient SafetyInitiative. Originally funded in FY 2001, fol-

lowing the November 1999 Institute of Med-icine report and continually funded sincethen, the AHRQ Patient Safety Initiative

seeks to identify, understand, and reduce themedical errors, risks, hazards, and harms

associated with health care system-relatedproblems. To support this initiative, AHRQ

developed a long-term plan that includesfour elements:

Identifying threats to patient safety Identifying and evaluating effective patient

safety practices Teaching, disseminating, and implement-

ing effective patient safety practices Maintaining vigilance

By awarding the PIPS grants, AHRQ hassought to encourage a national collaborative

effort to implement its long-term plan.

There currently are seventeen completed PIPSprojects. (See www.ahrq.gov/qual/pips.htm)

These existing projects have identifiedmedical errors, risks, hazards or harms;developed intervention and implementa-

tion plans; demonstrated the impact of theinterventions on the processes of care; and

determined that the interventions are wor-thy of wide-spread adoption. To facilitate

their use in other settings, comprehensiveimplementation tool-kits have been devel-oped for each project. They provide free,

publicly available guidelines to care settings

seeking to adopt any of the evidence-basedsafety practices.

Our DoD facilities have contracted to imple-

ment three of these existing projects. Dar-nall AMC has chosen to adapt the PIPS proj-ect titled: The ED Pharmacist as a Safety

Measure in Emergency Medicine. The proj-ect description suggests that by focusing on

the working conditions in the emergencydepartment (ED), this intervention

improves medication safety by implement-ing an ED Pharmacist program. The PatientSafety Newsletter will chronicle the experi-

ence of Darnall Army Medical Center as anexample of the PIPS collaborative at work

within the DoD. In this issue we will intro-duce readers to Darnalls process and plan.

In future issues we will follow along as Dar-nall implements the AHRQ project andshares its insights.

Carl R. Darnall Army Medical CentPIPS Proposal

The ED Pharmacist as a Safety MeasuEmergency Medicine

Darnall Army Medical Center presents a

fect setting for testing the efficacy of a cated Emergency Department (ED) pmacist. Located at busy Fort Hood, T

the ED at Darnall sees upwards of 7patients per year, with 200-250 patient

per day. One-third of the Armys pedipopulation is located in the Fort Hood

rons. The base is home to the Warrior Tsition Brigade. This combination of sppatient populations and high ED vo

made the leadership at Darnall espeinterested in safety practices directe

emergency medicine.

In May, 2007 Darnall formed a multidisnary team to develop a PIPS proposal aat adapting the existing AHRQ ED Pha

Pictured from left to right are: Shanae T. Riley, clinical pharmacist; Lt. Col. GwendolyThompson, Chief, Department of Pharmacy; Toby Cooper, clinical pharmacist, mem-bers of the Darnall AMC team implementing the AHRQ PIPS project.

Experiences and Suggestions From the FieldPATIENT SAFETY IN ACTION


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ist project. Originally developed by Rollin J.airbanks, MD, MS at the University of

Rochester, the project is centered on provid-

ng a dedicated pharmacist in the ED. Data

ollected by Dr. Fairbanks showed a directmpact on improved medication safety educed adverse drug events, improved med-

cation reconciliation and improved medica-ion adherence. The Darnall team, under the

direction of co-leaders Toby Cooper, Phar-

mD and LTC Sharon Reese,RN, DrPH, Chief,Nursing Research, worked directly with Dr.

airbanks to develop its own implementationlan, based on his original toolkit.

As expected, Darnalls military setting pres-nts unique opportunities and challenges.

The project has been backed by strong Lead-rship support from the outset. With its con-

ract now in place, Darnall envisions a fivetep implementation plan. Phase I hiring

n ED pharmacist may present the biggesthallenge of all. Dr. Cooper explains that uti-izing existing staff for this additional position

would stretch current personnel beyond opti-mal levels. However, a three to six month hir-

ng process,pharmacist shortages and recruit-ment difficulties are potential challenges to

mplementation as planned. For now, Darnalls working through the hiring process, hoping

to find a pharmacist with a doctoral leveldegree and residency training in emergencymedicine to staff this dedicated position.

Once hired, the ED pharmacist will beginPhase II of the project a six-month inte-gration process. Staff acceptance of a dedi-

cated pharmacist within the department isessential to its success. Building on initialpositive feedback from providers familiar

with ED pharmacists, Darnall has replicatedan internal perception survey used by Dr.

Fairbanks to gauge ED pharmacist accept-ance. To date, 70% of respondents welcome

an ED pharmacist and believe the positionwill improve quality within the department.Forty-five percent of respondents believe

that the pharmacist will have the greatestimpact as a consultant and instructor, assist-

ing with appropriate drug selection and tox-icology questions, and clarifying drug-to-

drug and drug-pregnancy interactions.

Following successful pharmacist integration,

the PIPS project will move into Phases III, IVand V. Phases III and IV are evaluative. They

will respectively measure the impact of theED pharmacist on medication errors (using

comparisons of data from retrospectivechart reviews and real-time measurements

during the Pharmacists tenure), and assesstaff acceptance and satisfaction with the EDpharmacist (by repeating the internal per-

ception survey at six months and one year)

In Phase V Darnall will share its findingsfrom the project across the Service and theDoD. If, as they expect, the ED pharmacis

proves to be a factor in reducing ED medica-tion errors, Darnall plans to create a permanent position for a dedicated ED pharmacist

In preparation for the project implementa

tion, Darnall is currently participating in amentoring program sponsored by the

American Society of Health System Pharmacists (ASHSP). Launched last year, thieffort, part of ASHSP's Patient Care Pro

gram, connects teams of ED pharmacistwith departments who wish to develop

these practices.

We invite our readers to follow the experi-ence of Darnall as it partners in this exciting patient safety initiative. As Madigan

and San Diego bring their projects on linewe will update their progress as well. Their

combined efforts remind us that the DoDis committed to improving patient safety

across the Military Heath System.

PATIENT SAFETY PHOTO ALBUM

he Patient Safety Team from Womack Army Medical Center participated in Retireeay activities at Fort Bragg, North Carolina Sept. 7-8, 2008. Led by Patient Safety

Manager Joyce Waller (pictured right; Jenifer Agee, PS Asst. on left) the team providedducational information to military retirees aimed at encouraging them to becomective participants in their own care. For more information on Army patient safetyctivities, see Patient Safety in the AMEDD, the US Army Patient Safety Center newslet-er ([email protected]).

This newly designed DoD Patient Safety Program exhibit booth was debuted at theAmerican Society for Healthcare Risk Management (ASHRM) conference, Boston, Massachusetts in early October. John Courtney, Senior Healthcare Analyst with the PSPexplains that the new abstract look reflects the current industry trend of conveying amessage through arresting visuals, rather than dense text and photographs. The mes-sage of the PSP booth, which features the words PATIENT SAFETY created with hun-dreds of eyes, is All Eyes On Patient Safety.

Patient Safety: All Day, Every Day Across the MHS


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In October 2008, more than 13,000civilian health organizations received afree copy of the TeamSTEPPS tool-

kit as a result of a partnership between theDepartment of Health and Human Ser-

vices Agency for Healthcare Research andQuality (AHRQ) and the Department of

Defense (DoD) Patient Safety Program.This inter-agency outreach effort began in

September 2007 to address the need andgrowing requests for both curriculum andguidance on training and implementation

of TeamSTEPPS. The AHRQ and DoDteamed with the American Institutes for

Research (AIR) to build a national train-ing and resource infrastructure to support

the dissemination, implementation andsustainment of TeamSTEPPS called the

TeamSTEPPS National Implementation

Project.

The recipients of the mass distributioninclude hospital CEOs, hospital Quality

Improvement Directors,State Hospital Asso-ciations, deans of medical schools and nurs-ing schools, and Quality Improvement

Organizations.

As of 1 October 2008 the TeamSTEPPSNational Implementation Project has

trained or registered 651 individuals for theTeamSTEPPS Master Trainer certification,representing 147 different organizations

across the U.S. These TeamSTEPPS MasterTrainers went on to report that they havetrained or are planning to train within the

next year 4,780 individuals from 119

organizations.

Outside of the U.S., the TeamSTEPPSNational Implementation Project hasgained international recognition and hasresulted in requests for additional training

from healthcare systems in Australia, theNetherlands, Japan, and Lebanon. In Octo-

ber 2008, the AIR team trained 45 physi-cians and nurses sponsored by the Tai-

wanese Department of Health and theirJoint Commission of Hospital Accredita-tion, with plans underway to implement

TeamSTEPPS at 500 healthcare institutionsthroughout Taiwan.

Additionally as part of the TeamSTEPPSNational Implementation Project, theThird Annual TeamSTEPPS Collaborative

conference will be held the first week ofJune 2009 at the Creighton University

Medical Center in Omaha, NE. Accordingto Heidi King, Deputy Director, DoDPatient Safety Program and Director,

Healthcare Team Coordination Program(HCTCP), it is hoped that this community of practice will continue to drive the

evolution and adaptation of teamwork bes

practices beyond federal agencies supporof the TeamSTEPPSNational Implementation Project.

At the DoD Patient Safety Program, initiatives like TeamSTEPPS ensure that safe

reliable care is delivered to every patient weserve, said Ms. King. More than 100 spe

cialty units and clinics have received somelevel of TeamSTEPPS training and are in

various stages of implementing in MilitaryTreatment Facilities. Over 1200 trainerscoaches have been trained in teamwork

principles.



TeamSTEPPSCOLLABORATIONBETWEEN DOD ANDAHRQ CONTINUES

Specialty Units Trainedor To Be Trained

CMS Quality ImprovementOrganization (QIO) internal staff

MRSA identified hospitals for QIOs Nursing orientation, preceptor

development General nursing staff ICU

OR surgical teams and anesthesiateams

Pharmacy ED Hospital resident staff Medical staff leadership Pediatrics Critical access hospitals Labor & Delivery NICU, post-

partum, baby nursery Required for re-appointment of

medical staff Respiratory therapy Technicians and unit secretaries

Medical/Surgical units Nursing homes

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

703-681-0064

PATIENT SAFETYPROGRAM 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: [email protected]: http://dodpatientsafety.usuhs.mil

E-Mail to editor: [email protected]

DIVISION DIRECTOR,PATIENT SAFETY PROGRAM

COL Steve Grimes

DIRECTOR, PATIENT SAFETY CENTERGeoffrey Rake, MDDIRECTOR, CENTER FOR EDUCATIONAND RESEARCH IN PATIENT SAFETY

Eric S. Marks, MD

DIRECTOR, HEALTHCARE TEAMCOORDINATION PROGRAM

Ms. Heidi King

SERVICE REPRESENTATIVESARMY

LTC Anthony BohlinNAVY

Ms. Carmen BirkAIR FORCE

Lt Col Anne Coyne

PATIENT SAFETY PROGRAM NEWSLETTER EDITORPhyllis M. Oetgen, JD, MSW

National ImplementationProject Expands

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Fall08 Dod Final

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