WINTER 2009 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

INSIDE: Patient Safety Awareness Week Opportunities

TRI-SERVICE DENTAL TRAINING A FIRST

he US Army Dental Command, nationally recognized in 2007 for its innovative dental patient safety promotion booth, has now turned its attention to TeamSTEPPS, the teamwork

training system designed to improve healthcare quality and safety developed by the DoD Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ).

Roberta Sjelin, RN, RDH, MA, MEDCOM Dental Patient Safety Coordinator facilitated the first Tri-Service dental Team-STEPPS training at Tripler Army Medical Center (AMC) in January, at the invitation of the Army’s Pacific Regional Dental Commander, COL William Bachand. The session, attended by over two hundred military and civilian dental professionals, was a unique TeamSTEPPS experience because it embedded a dental perspective into the standardized TeamSTEPPS curriculum. This, says Ms. Sjelin, was the key to making it an attractive opportunity for dental staff from Tripler AMC, Hickam Air Force Base and Koneohe Naval Station. Attendees watched video vignettes depict-

ing communication challenges during oral surgery and in a dental office, and were trained by a team which included dental personnel familiar with the TeamSTEPPS curriculum.

Adapting the TeamSTEPPS concepts, scenarios, tools and trainers to the dental setting, Ms Sjelin believes, has brought more validity to the training for its dental audience. It has also prompted

dental provider buy-in and leadership support – critical compo-nents of TeamSTEPPS success no matter the setting or branch of service. An added incentive for the tri-service attendees in Hawaii was the provision of Continuing Education credit.

Interest in TeamSTEPPS among dental providers within the DoD and beyond continues to increase. Plans are underway for more training in the U.S. and Europe this year. The Public Health Service, the Institute of Healthcare Improvement and the Ameri-can Dental Association have all been in contact about the Army’s unique dental adaptation of TeamSTEPPS.

Army Dental Command Organizes TeamSTEPPS Training

T

Participants in Tri-Service dental TeamSTEPPS training make paper chains as part of an ice-breaker exercise illustrating communication challenges. Pictured with civilian attendee are LT Thomas Atkin, HN Hargrove from the Navy, and Army SPC Donald Knollenberg.

“Most important to TeamSTEPPS for dental personnel is training by dentists who can ‘talk

dental’ to the audience”Roberta Sjelin, Nurse Consultant, Dental Patient Safety, MEDCOM PSC

TABLE OF CONTENTS 2 Dot-Mil-Doc 3 Mobile OB Simulator at 374 MDG 4 Reynolds ACH Shares HFMEA

Too busy to read? Tune into Pentagon Web Radio on BlogTalkRadio. Dot Mil Docs, a weekly feature of Pentagon Web Radio, produced by the Office of the As-sistant Secretary of Defense for Health Af-fairs, is designed to discuss military health concerns. The interactive network provides informative thirty-minute radio podcasts on a variety of health-related topics.

Of special interest to the patient safety community are two recent episodes detailing the introduction and continued implementation of TeamSTEPPS in the Combat Support Hospital, Baghdad, Iraq. Episode #35 features Army COL Peter Napolitano, M.D. describing pre-training efforts and the importance of the Huddle. In Episode #41, MAJ Shad Deering, M.D. and MAJ Amber Pocrnich, both of whom are currently deployed, provide an update on TeamSTEPPS training in theater and discuss its impact on patient safety.

Two upcoming podcasts are designed to commemorate Patient Safety Awareness Week, which runs March 8 through 14, 2009. On Show #49, airing at 2:00 pm on March 10, Col Lee Payne, United States Air Force, will provide an overview of the impact of TeamSTEPPS on the quality of healthcare at the David Grant Medi-cal Center Simulation Center, Travis Air Force Base. The Rapid Response System at US Army Medical Command, Fort Sam Houston, Texas will be the focus of Show #50. United States Army LTC Eric Craw-ley, a subject matter expert and long-time champion of the Rapid Response System, will be the featured guest on the show, to air March 12th at 2:00 pm.

To access Pentagon Web Radio, register with BlogTalkRadio at www.blogtalkradio.com. Enter “Patient Safety” in the search option. You can also access Dot Mil Docs in the “What’s New” section of the DoD Patient Safety Program website at: http://dodpatientsafety.usuhs.mil.

The newly-designed Patient Safety Program exhibit booth attracts visitors at the various national conferences where it is displayed. Sporting an updated image and conveying the message “All Eyes On Patient Safety”, the booth provides materials which showcase the range of patient safety initia-tives across the MHS. Pictured here is Ms. Judy George, Senior Health Analyst, Patient Safety Program, manning the booth at the IHI Conference in Nashville in Decem-ber 2008. Exhibit plans for 2009 travel include the Association of periOperative Registered Nurses (AORN) Conference in Chicago, IL in March, and the National Patient Safety Foundation (NPSF) Confer-ence, Washington, DC in May.

PENTAGON RADIO NETWORK FEATURES DOT-MIL-DOCS

PATIENT SAFETY IN ACTION

Recent Episodes Highlight TeamSTEPPS Training In Theater

Experience and Suggestions From Across the MHS

PATIENT SAFETY PHOTO ALBUMPatient Safety: All Day, Every Day Across the MHS

2 WINTER 2009 PATIENT SAFETy

Mobile Obstetrical Emergency Simulator (MOES) has arrived at the 374 MDG, Yokota Air Base, Japan! The simulator re-creates a variety of obstetric emergency situations. The computer-driven full-size adult mother mannequin and fetus mannequin are interactive and operated by an instructor watching from the wings. These dummies are highly sophisticated and prove the popular wisdom that “you can learn a lot from a dummy.”

The 374th Medical Group was fortunate to land this great opportunity. Mr. Scott Chittenden, Patient Safety Manager at the 374th MDG first learned of the hi-fidelity simulator through research into Partners to Improve Patient Safety (PIPS). He believed that the simulator would be a creative response to the concern that up to forty percent of maternal deaths in the United States are potentially preventable and often related to obstetric care during emergen-cies, as well as the related Joint Commis-sion requirement that emergency drills become part of routine training.

It is well accepted that training on high-fidelity simulators improves pilots’ perfor-mance. The simulator-training concept was applied to DoD healthcare over five years ago, beginning with efforts at Madigan

Army Medical Center. Previous simula-tions (ACLS, PALS, OREs) have looked at either technical proficiency or teamwork, but rarely both of these key components together to improve patient outcomes. The 374th MDG mobile OB project will incor-porate specific TeamSTEPPS skills into the MOES drills to combine individual and team proficiency training in a unique way. Not only will this improve our teaching

methods for emergency deliveries, it will promote and enhance our team perfor-mance and communication.

Maj Lon Taff, M.D., Medical Director of OB services, and Maj Krisandra Smith, Surgical Specialty Flight Chief, are points of contact for interested providers with OB privileges and nurses interested in cross-training with the OB ward.

Dr. Lon Taff, MC, Maj, USAF introduces 374 MDG Family Care Unit Staff to MOES. Pictured left to right are: Maj Cruz, Capt Evans, Lt Myers, Maj Roberts, Capt Fabre, SrA Badger, Capt Gomez, Tsgt Johnson and Dr. Taff.

The 35th Medical Group at Misawa Air Base, Japan, recently upgraded its Rapid Response system. It replaced its original gurney with the new one pic-tured here — a state-of-the-art Stryker gurney with a weight capacity of up to 300 kg. The new gurney will make transporting a patient in need of further evaluation and treatment in the Urgent Care Center much safer for both the patient and the rapid response team. Pho-tograph provided by Paul H. Sayles, BA, LVN, Contract Patient Safety Manager, 35 MDG.

374TH MEDICAL GROUP INCORPORATES MOBILE SIMULATORState of the Art Training Combines Emergency and Teamwork Skills

Scott Chittenden, RN, HRM, MBAContract Patient Safety Program Manager

Patient Safety: All Day, Every Day Across the MHS

WINTER 2009 PATIENT SAFETy 3

Prior to The Joint Commission January 2008 National Patient Safety Goal initia-tives and the May 2008 Sentinel Event Alert (“Preventing Pediatric Medication Errors” Issue #39) Reynolds Army Com-munity Hospital (RACH) and Major Saun-dra Stinehart (Head Nurse, Progressive Care Unit) identified the pediatric popula-tion as a high risk low volume population. Following these publications, however, a Healthcare Failure Mode Effects Analysis (HFMEA) was conducted to determine “failure modes” and “potential failure modes” within their pediatric population. MAJ Stinehart also conducted a Needs As-sessment to determine pediatric care needs throughout the facility.

The findings reflected that policies and procedures needed updating, and that

the staff was requesting more age specific training. The review of data revealed that pediatrics, although accounting for only a small percentage of inpatient admissions, generated a higher percentage of the Medi-cation Related Incident Reports – a finding unfortunately consistent with national data.

The HFMEA Hazard Score was used to determine the highest risk and priority. The top four areas of concern were selected. MAJ Stinehart designed action plans that called for a broad range of changes, standardizations and a return to basics to eliminate or decrease the risk factors within pediatrics.

A variety of actions were undertaken to reduce the risk of medication errors: a pediatric medication training program was implemented; a best practice medication prescribing protocol for pediatrics was initiated; and nurses began using a double verify method for all pediatric medications. The lack of standardized hospital pediatric

protocols was resolved by revising RACH “Care of the Minor Child” Policy, which was introduced during RACH Newcom-ers training and Annual Skills Fair. The need for further age based training was incorporated into the monthly unit level staff meetings to continually reinforce its importance. Finally, the need to tighten security to prevent possible abduction or child mix up was addressed by placing a hospital-specific, color-coded identification band on all children (not just newborns) and their parents. The identification bands have increased the visibility of the vulner-able pediatrics population, and remind the RACH healthcare team to stop, look and verify to identify families and prevent pos-sible abductions.

With its proactive healthcare environ-ment RACH has raised the bar for standard-ization, quality and teamwork for pediatrics, and has proudly put itself on the cutting edge of patient safety and risk reduction.

RACH Hospital Commander COL Ellen Forster, who approved the Pediatrics HFMEA and MAJ Saundra Stinehart, HFMEA Process Design Expert and Team Leader pose with the HFMEA team. Pictured, front row, left to right: Ms. Charlotte Stevenson, Patient; Safety Manager; MAJ Stinehart and COL Forster; back row, left to right: CPT Daniel Tolson, Pediatric Physician; Ms. Carolyn Patterson, Chief Quality Services Division; COL David Peterson, Deputy Commander for Patient Services.

Results Lead to Updated Policies and Tightened Security

Saundra Stinehart, MSN, CNS, APRN-BCMAJ, AN, US Army Clinical Nurse Specialist, Medical-Surgical-Pediatrics (PCU), ANCHEP Coordinator

REYNOLDS ACH CONDUCTS PEDIATRIC HFMEA

4 WINTER 2009 PATIENT SAFETy

The DoD Patient Safety Program hosted the second meeting of the National Health-care Safety Network (NHSN) Workgroup on January 22-23 2009 in San Antonio, Texas. The meeting brought together over thirty Infection Control Professionals (ICP) and Infection Preventionists (IP) from each of the Services, Patient Safety, Clinical Quality, and Service headquarters for a two day follow-on to its inaugural meeting in August.

The meeting centered on the DoD use of the Centers for Disease Control and Prevention’s (CDC) National Health Care Safety Network. CAPT Teresa Horan, USPHS, CDC, Division of Healthcare Quality Promotion provided perspectives and current initiatives in Infection preven-tion which included the themes: • Promoting elimination of healthcare as-sociated infections (HAI) • Promoting 100% adherence to proven prevention practices • Measuring progress • Aligning systems to minimize the burden on providers of data • Pay for performance (P4P) and non pay for performance (NP4P) • Mandatory public reporting CAPT Horan also discussed current func-

tionality in NHSN and new functionality on the horizon – new options, modules and components in NHSN including Central Line Insertion, Influenza in High Risk Inpatients and Healthcare Worker – Blood and Bodily Fluid Exposure and what modules the various states are mandating for infection control reporting. She also provided an in-depth pre-release introduc-tion and demonstration of the new Multi-drug Resistant Organism (MDRO) module in NHSN. CAPT Horan concluded with a question and answer session for members of the workgroup.

Each of the Services briefed the work-group on the sites it plans to implement in the second phase of the DoD roll-out of NHSN. These include: Army • Martin Army Community Hospital • Winn Army Community Hospital • Blanchfield Army Community Hospital • Brook Army Medical Center • Wormack Army Medical Center • D.D. Eisenhower Army Medical Center • Tripler Army Medical Center. Navy • Naval Medical Center San Diego Air Force • Eglin AFB

• Elmendorf AFB • Keesler AFB

This will make a total of twenty of our larger inpatient medical facilities using NHSN to track Ventilator Associated Pneumonias (VAP) and Central Line As-sociated Bloodstream Infections (CLABSI) in facilities with intensive care units (ICU). Sites were encouraged to use other mod-ules as appropriate based on their indi-vidual site risk assessment. The Services also discussed their individual challenges to implementing NHSN, lessons learned and suggestions for improving the imple-mentation process for the new DoD sites implementing NHSN.

Day two was devoted to the transition of the NHSN Workgroup to the Infection Prevention and Control Panel, a sub-com-mittee of the MHS Clinical Quality Forum. Discussions were far-reaching and included topics from ICP training required by the various Services to professional organiza-tions of interest to ICPs.

The meeting ended with a presentation on antibiotic resistant organisms provided by the Navy-Marine Corps Public Health Center – Epidata Center.

INFECTION PREVENTION WORKGROUP UPDATEWorkgroup Transitions to Infection Prevention and Control Panel

In September 2008, the Source Selection Evaluation Board for the Patient Safety Reporting project chose Datix Ltd. software to provide a standardized patient safety event reporting tool across the Military Health System (MHS). Datix is a global supplier of software for patient safety, risk management, incident and adverse event reporting. Datix is provided as a standard package but its unique configuration features make it flexible enough to be tailored to meet the requirements of any healthcare organiza-tion worldwide. Founded in 1986, Datix has over 400 customers, which include more than three quarters of the National Health Service in the United Kingdom and major implementations in Canada. Datix is headquartered in London, United Kingdom. In response to the National Defense Authorization Act for FY 2001 which specified that the Secretary of Defense will “imple-ment a system of indicators, standards, and protocols necessary to track patient safety,” PSR will provide for recording, collec-tion, storage management, real-time analysis, and reporting of event information rapidly and accurately through the use of dy-namic screens and role-based security. PSR data will be utilized

at the Military Treatment Facilities (MTFs), Service and Enter-prise levels to support care process redesign, to make healthcare safer for our military and their beneficiaries.

Northrop Grumman was selected as the integrator to install the Datix software for web-based access, configure the applica-tion to meet the MHS requirements, and train personnel. System Qualification Testing (SQT) will be conducted in May. Repre-sentatives from the nine limited deployment Military Treatment Facilities, Service Headquarters, Patient Safety Center and the Patient Safety Program will participate in SQT. A successful SQT will trigger the submission of the Milestone C package for review. A limited deployment decision is expected by September 2009.

A web-based training series developed by Northrop Grum-man will be released on MHS Learn and classroom training will be scheduled in October 2009. During the 90-day limited deployment, Operational Test and Evaluation (OT&E) teams will observe and interview PSR users. Full rate deployment will commence after a complete review of the OT&E report. Full Op-erational Capability will be achieved on or before September 2010.

PATIENT SAFETY REPORTING PROJECTTesting and Limited Deployment Scheduled

WINTER 2009 PATIENT SAFETy 5

JOIN In Annual NPSF-Sponsored Patient-Centered Event

The National Patient Safety Founda-tion (NPSF) is again inviting hospitals and healthcare organizations around the country to join in Patient Safety Awareness Week, March 8-14. This national educa-tion and awareness-building campaign for improving patient safety at the local level encourages events that educate patients on how to become involved in their own health care. The Week is also meant to foster partnership activities between hospi-tals and their patient communities.

Military Treatment Facilities (MTFs) across the Military Health System have a history of enthusiastically celebrating Patient Safety Awareness Week. In year’s past, activities have included games like patient safety Jeopardy and Poker, poster contests, patient-centered displays and handouts, school visits, radio shows and articles explaining patient safety.

This year MTFs are again encouraged to observe Patient Safety Awareness Week. If you still need ideas or guidance you should access the NPSF website at www.npsf.org, and click the Patient Safety Aware-ness Week link. A long list of activities for Patients and Families, as well as for Hospi-tals, Healthcare Organizations and Staff is available, as is the Patient Safety Awareness Week logo download and a free Patient Safety Awareness Week Toolkit available to Stand Up for Patient Safety members.

LEARN With Special DoD PSP Website Awareness Week Leader-ship Session

As your facility celebrates Patient Safety Awareness Week, leadership is encouraged to access the Patient Safety Program web-site at http://dodpatientsafety.usuhs.mil for an exciting learning opportunity. On Wednesday, March 11, 2009 from 10:00 to 11:00 am (EST) the DoD Learning Action Network will sponsor a Webinar entitled Creating a Culture of Patient Safety. This special leadership session will be led by speakers David Musson, MD and Kather-ine Jones, PT, PhD. Dr. Musson, profes-sor of Anesthesia at McMasters University in Ontario, Canada has been active in de-

veloping safety culture competencies across multiple heathcare pro-fessions. He will share a comprehensive set of best practices aimed at improving the culture of safety. Professor Katherine Jones from the University of Nebraska is an expert at analyzing culture survey results and creating integrated team-based safety solutions for change. Together these two subject matter experts will help you learn how to meet the 2009 Joint Commission Leadership Standard for a culture of safety, learn how to interpret your MHS Patient Safety Survey results, and learn how to identify opportuni-ties and apply evidence-based tools for improvement in your facility.

SHARE Your Experiences

As you observe Patient Safety Aware-ness Week with patients and staff, we ask you to record your activities. Write

a short paragraph describing how your facility marked the occasion, take photo-graphs of your activities, and send them to the Patient Safety Newsletter for inclusion in our annual Spring Patient Safety Awareness Week review. Pictures can be sent directly to the newsletter editor at poetgen@aol.com, or can be forwarded through your patient safety service representative.

PATIENT SAFETY AWARENESS WEEK Annual Event Has Patient-Centered Focus

Published quarterly by the Department of Defense (DoD) Patient Safety Center to highlight 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 703-681-0064Forward comments and suggestions to:

DoD Patient Safety Center Armed Forces Institute of Pathology 1335 East West Highway, Suite 6-100 Silver Spring, Maryland 20910 Phone: 301-295-7242 Toll free: 1-800-863-3263 DSN: 295-7242 • Fax: 301-295-7217 E-Mail: patientsafety@afip.osd.mil Website: http://dodpatientsafety.usuhs.mil E-Mail to editor: poetgen@aol.com

DIVISION DIRECTOR, PATIENT SAFETY PROGRAM COL Steve Grimes

DIRECTOR, PATIENT SAFETY CENTER Geoffrey Rake, MD

DIRECTOR, CENTER FOR EDUCATION AND RESEARCH IN PATIENT SAFETY Eric S. Marks, MD

DIRECTOR, HEALTHCARE TEAM COORDINATION PROGRAM Ms. Heidi King

SERVICE REPRESENTATIVES ARMY LTC Anthony Bohlin

NAVY Ms. Carmen Birk

AIR FORCE Lt Col Anne Coyne

PATIENT SAFETY PROGRAM NEWSLETTER EDITOR Phyllis M. Oetgen, JD, MSW

PATIENT SAFETY PROGRAM NEWSLETTER

6 WINTER 2009 PATIENT SAFETy