psc newsletter 2004 summer

8/14/2019 PSC Newsletter 2004 Summer

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THREE YEARSOF PATIENT

SAFETY NEWSNewsletter Chronicles Progress

This summer 2004 issue marks thethird full year of publication forthe Patient Safety Newsletter. TheNewsletter was first published in August,2001, following successful pilot testingof the patient safety reporting system,establishment of the Patient Safety Centerat AFIP, and the first patient safety train-

ing session.

A glance back through the Newslettersproduced to date provides an overviewof the progress of the DoD Patient SafetyProgram. The fall, 2001 issue describedthe introductory patient safety trainingprovided to107 attendees; this summerthe Center for Education and Researchin Patient Safety offered advanced train-ing to a full complement of patient safety

managers. Newsletters in 2002 encour-aged more widespread use of MED-MARX, MedTeams and Medical TeamTraining. As reported in the spring 2004Newsletter, MEDMARX today is an inte-gral part of DoD reporting and training,

while Medical Team Training has beenintegrated throughout the services.Newsletters in 2003 heralded therestructuring of the Patient Safety

Program and the launch of the PatientSafety website. This years WinterNewsletter covered the First Annual

Patient Safety Awards, showcasing a trioof innovative efforts in the fields ofTechnology, Policy and Procedure andTeam Training.

ThePatient Safety in Action feature hasacted as a tri-service bulletin board

where treatment facilities share success-ful initiatives. In 2001 and 2002 educa-tion and basic communication skills

were being tried and tested. Facilities

have since extended their patient safetyefforts, bringing automation to theBethesda pharmacy and JCAHO safetygoals to the Dover AFB ambulatory careclinic in 2003. This year the Navy stan-dardized its list of dangerous abbrevia-tions to meet JCAHO Patient Safety Goalrequirements.

As the Newsletter begins its third year ofpublication, it is fitting that our focus issuccess. Each page in this issue high-

lights initiatives which move patient safe-ty from a basic to a more advanced leveland reflect and the maturation of thePatient Safety Program.

Editors Note: Access past issues of thePatient Safety Newsletter on the DoDPatient Safety Program website:https://patientsafety.satx.disa.mil

F0011

Page 2 RCA Database

Page 3 Air Force Training

Page 4 AMEDD Trauma Teams

Page 7 Navy WalkRounds

A quarterly newsletter to assist DoD hospitals with improving patient safety

SUMMER 2004PatientSafety

FOCUS:PATIENT SAFETY SUCCESSES

EISENBERG AWARD

GOES TO ARMY

INITATIVE

Congratulations MAJ(P) Danny Jaghab

MAJ(P) Danny Jaghab is the recipient the 2004 John M. Eisenberg Award fPatient Safety and Quality for systems innovation at the national level. The award will bepresented on October 6, 2004 at the NationQuality Forum meeting.

MAJ(P) Jaghab, a registered dietitian, currely Nutrition Staff Officer at the U.S. Army

Center for Health Promotion and PreventiveMedicine, created the MPEG Training Prograt Brooke Army Medical Center in 2003,

where he was Dietetic Internship Director. preparation for the hospitals JCAHO surveyMAJ(P) Jaghab wrote three two-minute scrifor each patient safety goal and recommendtion, which he converted into Motion PicturExpert Group (MPEG) format. Made availaon the Brooke intranet, the thirty-four scripseries provided a comprehensive patient saftraining program, commended by JCAHO as

nationally outstanding example of best practices.

The Eisenberg Award brings well-deservednational recognition to MAJ(P) Jaghab, andthrough his efforts to the Military HealthSystem Patient Safety Program. Look for fulcoverage of the award presentation in the faNewsletter. Access the MPEG TrainingProgram at: https://patientsafety.satx.disa.m


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2

NEWS FROM THE

PATIENT SAFETY

CENTERFeedback and SuggestionsBased on Your Reporting

PSC REFINES RCAANALYSIS

Database In Development;

Feedback Form IntroducedBy: Mary Ann Davis, RN, BSN, MSANurse Risk Manager, Patient SafetyCenter

T

he Patient Safety Registry staff hasbeen busy reviewing Monthly

Summary Reports and Root CauseAnalyses (RCAs) submitted to thePatient Safety Center (PSC). TheRegistry has collected almost two yearsof data. The Monthly Summary Reportdata has been imported into a databasesince the Excel spreadsheet was intro-duced in November of 2002. By usingthis database the PSC has been able togenerate basic statistics and reports.

The PSC has been receiving RCA reportsin various forms and with varied datafor incidents that have occurred overthe past few years. We have long recog-nized the need to create a database totrack root causes, corrective actionsand outcomes measures as well asdemographics, and we are now in themidst of developing a relational data-base management system to organizethe RCA data.

The DoD military treatment facilities(MTFs) are utilizing both theTapRooT system for root cause analy-sis and the designated DOD RCA form.This has assisted in the development ofthe database. Consistent formats help

the Registry collect data and enable cat-egorization of the information. Since thedatabase consists of tables, each bit ofinformation that can be categorized isplaced into a table and then retrieved todevelop queries and reports. This infor-mation will help track trends, focus onproblem areas, and disseminate useful

information to facilities. Once the data-base, which should become functional

within the next three to six months, isfully operational, the PSC will be able toshare findings derived from its use.

Services and MTFs have requested feed-back on the RCAs submitted to thePatient Safety Center. In response, thePSC has developed and introduced anRCA feedback form, which contains an

itemized checklist and general com-ment report. The initial feedback form

was sent out to the Service representa-tives in the beginning of July. IndividualMTFs will receive the feedback formfrom their Service representatives. Thefeedback form allows the PSC to shareinformation on areas in the RCA that itfinds exceptional or that may need to beexplored with future submissions. Thefeedback forms will be used for RCA

events occurring in 2004 and receivedby the PSC after June 1, 2004.

The Registry would like to thank thefacilities for using the DoD RCA formand TapRooT. We have found thatusing system analysis and the DoD formhas enabled the staff to review and ana-lyze the information quickly and effec-tively. Your valuable work and coopera-tion have helped in the development of

the database.

Patient Safety LinksInteresting Resources To Explore

Pediatric patient safety issues are dis-cussed in the following recent articles:

USP Patient Safety CAPSLink

www.usp.org

Pediatric Population Requires Special

Vigilance to Ensure Safety

Analysis of data from USPs MEDMARX

on medication errors in pediatrics popula-

tion.

Premier Safety Share

www.premierinc.com

July, 2004

Very Young and Poor At Higher Risk of

Medical Errors

Synopsis of AHRQ funded study confirm-

ing medication errors are significant

problem for children. Link to report of

the study published in June 2004 issue of

Pediatrics.

Health Affairs

www.healthaffairs.org

Exploring the Business Case for

Improving the Quality of Health Care for

Children

July/August 2004, Vo. 23, No. 4

Results of an expert panel sponsored by

AHRQ to analyze the business case for

childrens health care identify barriers

and solutions.

Also see Health Affairs, July/August 2004

issue for:

Measuring Patients Trust in Physicians

When Assessing Quality of Care

Discussion of importance of measuring

trust and need to evaluate cost benefits.

The Working Hours of Hospital Staff

Nurses and Patient Safety

Study suggests risk of error significantly

increases when nurses work more than

twelve hours/day, forty hours/week and

during overtime.

Premier Safety Share

www.premierinc.com/all/safety/publica-

tions/06-04_full_txt.html

June 2004

Premier Releases Results of Survey on

Disclosure Practices

Anonymous survey of over 200 hospitals

confirms disclosure increasing; biggest

barriers are financial consequences and

public stigma.


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HAVE

TRAINING...

WILL TRAVEL

Aviano Training Session A First

Inspired by his strong commitment topatient safety, Col Lee Payne,Commander of the 31stMedical Groupat Aviano Air Base, Italy invited Lt ColBeth Kohsin, Air Force Patient SafetyProgram Manager, to conduct a patientsafety education session on site. TheMay 2004 class was the first time the

Air Force has exported its patient safetytraining to an individual facility, and it

marks a next step adjunct to patientsafety education for the Service. Whilethe introductory and advanced DoDtraining sessions stateside form the coreof patient safety education, offering site-specific, facility-wide classes allows atargeted, personalized re-enforcementof patient safety fundamentals.

The 31stMedical Group at Avianoespouses safety as its #1 priority, and itscreative approach to training leaves no

doubt that it is willing to devote timeand resources to its goal. A full fourhours was devoted to the patient safetyclass, which was attended by over thirtymembers of the Medical Group repre-senting all levels of leadership and unit

patient safety monitors. Discussionamong attendees was especially ener-getic. They agreed that learning on siteand together with co-providers encour-aged a lively exchange of ideas and

ready assimilation of theoretical knowl-edge for the practical benefit of theirpatients.

The 31stMedical Group took this edu-cational opportunity to underscore itscommitment to a culture of patient safe-ty at the facility, as well as throughoutthe Service. Following their own patientsafety training, Aviano hosted medicalteam training for five European AirForce bases, facilitating the addition of

fourteen new instructors to the AirForce cadre. Leadership also presentedthe 31stMedical Groups first patientsafety award. The Take Time ForPatient Safety award, conceived by

Valorie Davidson, Patient SafetyProgram Manager, and Suzanne Green,Patient Safety Program Assistant, is a

visible recognition by leadership of staffparticipation in patient safety improve-ments. It is intended that quarterlypresentation of this award will focus

staff attention on patient safety andincrease near miss reporting through-out the facility. The first recipients ofthe award (pictured below) submitted afailure mode and effects analysis(FMEA) on post-op monitoring.

3

AIR FORCE SUCCESSES AT HOME AND ABROAD

AIR FORCE

RECEIVES

AWARD

Patrick AFB Program Honored

On June 15, 2004 the AmericanPharmacists Association (APhA)Foundation presented its Pinnacle

Award for Government Agencies/Non-profit Organizations to the US Air ForcePharmacy/Patrick Air Force Base. ThePinnacle Awards recognize contribu-tions to health care quality through themedication use process.

Air Force Pharmacy, composed of over1,300 pharmacists and technicians,undertook a comprehensive program tomaximize pharmaceutical benefit acrossthe Air Force by optimizing the medica-tion dispensing process to improve safe-ty, efficiency and patient outcomes.Implementation of the MedMARx med-ication error database resulted in a56% reduction in errors; efforts to stan-

dardize patient medication informationusing laser printers increased medica-tion adherence by 25%; use of techno-logical enhancements and regional refillcenters decreased prescription fillingtime by 39%.

Patrick Air Force Base was cited for itsdramatic improvement in patient out-comes with dyslipidemia patients. Apharmacist-run patient

education/polypharmacy clinic and lipidclinic were developed; pharmacists col-laborated with physicians to avoidpotentially unsafe drug combinationregimens; and a series of three educa-tional programs were conducted forproviders. The program resulted indecreased LDL and increased treatmentadherence for patients.

Recipients of the Take Time for Patient Safety award at Aviano Air Base: Lt ColSherry Cox, Maj Kenneth Williams, Capt Ross Sutherland, SSgt Bradley Strable andPatient Safety Program Assistant Mrs. Suzanne Green.


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FORWARD SURGI-

CAL TEAMS ADAPT

TEAM TRAINING

Curriculum Revised To Include

Focus on TeamsBy: LTC John H. Armstrong, MD, Director,ATTC; LTC Kimberly K. Smith, RN;MAJ Michael L. Schlicher, RN

The radio crackles in the early morn-ing hours at the 126th ForwardSurgical Team. The medics voice is barelyheard over the whoosh of the helicopterblades and the screams of the traumapatient. Good morning 126th FST, we arein route to your facility with a twenty-one

year old male patient involved in a motorvehicle collision. He appears to have a pos-sible amputation of the right lower extremi-ty. The Glasgow Coma Score is 13 and weare starting two IVs. We should be at yourfacility in about 15 minutes.Without hesitation, the FST readies theirteam to accept their 8th trauma patient ofthis very early day.

Meanwhile, the FST Commander, ChiefNurse, Executive Officer, and DetachmentSergeant are finishing up their daily updatebriefing. Patient census, personnel events,training schedules, logistical needs, andother matters of situational awareness werediscussed to ensure that all are on thesame playing field and have the samegame-plan. They prepare to pass thisinformation on to the remaining sixteenFST members who are busy readying thehospital to accept more casualties. Thedaily update briefing concludes as the com-bat medic alerts them to the incomingpatient.

The primary nurse quickly observes that allthe right supplies and equipment are in theright place for the incoming trauma resus-citation. The team members have preparedtheir work environment in advance. Theprimary surgeon and the two combatmedics join the primary nurse to reviewtheir team roles for the patient resuscita-tion. Team talk is used frequently in their

discussion. (See appendix A for team talkdefinitions). The FST member has incorpo-rated the team dimensions into their prac-tice. They are all on the same playingfield when the critically injured patientarrives. The team performs their mission

quickly and precisely as the patient is safelyresuscitated and prepped for the operatingroom. They meet afterwards for an afteraction briefing where they review their per-formance using the TIPS (Team InputPromotes Success) cards. The TIPS cardsallow each team member to collect theirthoughts and feedback related to the over-all and individual performance of the team.This feedback is discussed as a team andused to help improve patient safety andteam performance through effective com-munication. The team was prepared for

their mission, they were clear on individualand collective roles, and team communica-tion throughout the resuscitation revolvedaround the patient with team tasks (see

Appendix B for Critical Team Tasks) rein-forced. A few suggestions for improvementwere agreed upon. As the team beganrestocking the resuscitation area, the radioalerts to yet another trauma patient on theway.

Team training is crucial to mission successfor the FST. These twenty member teamsare composed of surgeons, anesthetists,critical care and emergency nurses, andcombat medics. Their mission is to providefar forward life saving surgical support toour airmen, sailors, and soldiers on thefrontlines of the battlefield. The FST mustbe precise in surgical care and team sup-port under hostile and austere environ-ments. The majority of the Armys activeduty and reserve FSTs have been deployed

in the past three years in support ofOperation Enduring Freedom andOperation Iraqi Freedom.

4

ARMY SUCCESSES MOVE TO FRONTLINES

TEAM TALK

GAMEPLAN the BIG picture relevant facts/relationships/sit-reps/op-ords defining an event, situation,

or problemPLAYING FIELD real time situation, reality

extent to which team members are aware of particular events, status oroperational issues that impact the team

CALL-OUTS critical information called out airway clear

ECHO verify all medical verbal orders verbatim, acknowledge all operational

orders, all unclear written orders I echo

COVER YOUR BUDDY backing, Ive got your back monitoring the actions of other team members

EMPOWERED INTUITION time-out speaking out in support of a different course of action stating in a pro-

fessional manner a position with conviction

DRIVE ON leader acknowledges the call for time-out, but must drive-on and

discuss at a later time due to emergency on hand

INSTANT REPLAY replay assertively voice opinion at least twice to assure having been heard

PASS- I pass this to you transfer responsibility and accountability during team transitions

APPENDIX A

continued on page 5


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5

The 126th

FST is one such team, yet theirmost recent trauma care experiences didnot occur in the combat theater. Theyoccurred in the busy Ryder TraumaCenter which is co-located with JacksonMemorial Hospital and the University ofMiami located in Miami, Florida.Operating within this busy inner city hospi-tal one finds the innovative and dynamicmedical team training program, the ArmyTrauma Training Center (ATTC). The 126th

FST just concluded their clinical deploy-ment training rotation at the ATTC.

The Army Trauma Training Center (ATTC)provides clinical deployment training byimmersing the FST into a dynamic traumamilieu with emphasis on total team train-ing. The ATTC was opened by the ArmyMedical Department Center and School infall of 2001, in recognition that FST clinicaltraining in a controlled setting should pro-duce better outcomes on the battlefield.The Ryder Trauma Center offers that settingwithout deployment and is one of thenations busiest trauma centers caring for

over 3600 level one trauma patients peryear. The FST is quickly integrated into thisenvironment to provide care for the largenumbers of penetrating (gunshot and stabwounds), blunt (automobile, industrialaccidents), and burn trauma patients.Twenty-six of the Armys active duty andreserve FSTs have received training at theATTC thus far.

The ATTC has recently incorporated med-ical team management into its training doc-trine. The Tricare Management Activityteam training curriculum forms the founda-tion of the new ATTC program of instruc-tion. This intense 14 day in the boxtraining program is infused with the teamtalk, team tasks, and team developmentdimensions that form the cornerstone ofthe AMEDD patient safety initiative. TheATTC is moving this initiative into the com-bat theater by training FSTs in team dimen-

sions that provide safe, effective traumacare. These trained teams have been citedin OEF/OIF by Dr. William Winkenwerder,Assistant Secretary of Defense for HealthAffairs, as one of the reasons for the lowestdied of wounds rate in recorded warfare.Bringing team training into combat casualty

care through the training program at theATTC exemplifies the energy and commit-ment of the AMEDD Patient Safety Program.The ATTC is honored to be recently desig-nated as the Center of Excellence inCombat Casualty Care Team Training.

5 TEAM CONCEPTS

CRITICAL TEAM TASKS

MAINTAIN TEAM STRUCTURE AND CLIMATE

establish leader

designate roles and responsibilities

communicate essential team information

acknowledge contributions of team members to team performance

demonstrate mutual respect in all communication

hold each other accountable for team outcomes

address professional concerns directly

resolve conflicts constructively

PLAN AND PROBLEM SOLVE

engage team members in planning & decision making

establish a shared mental model

communicate the plan of action

cross-monitor team member action

advocate and assert a position or corrective action

apply the two-challenge rule

IMPROVE TEAM SKILLS

conduct shift reviews

conduct event reviews

engage in situational teaching and learning with the team engage in peer coaching with team members

participate in formal case conferences that include teamwork

considerations

address contributions to teamwork in individual performance appraisals

MANAGE WORKLOAD

manage workload

replan patient care in response to overall caseload of team

prioritize tasks for the individual patients

balance workload within the team

offer assistance for task overload

constructively use periods of low workload

COMMUNICATE WITH THE TEAM

request and provide situation awareness updates to team members

use standard terminology in all team communications

use the check-back system to verify information transfer

call out critical information during emergent events

systematically hand off responsibility during team transactions

communicate decisions and actions to team members

APPENDIX B

FORWARD SURGI-

CAL TEAMS ADAPT

TEAM TRAINING

Curriculum Revised To Include

Focus on Teamscontinued from page 4


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6

DoD PATIENT SAFETY WEBSITE

The DoD Patient Safety Website is nowaccessible at this new address:https://patientsafety.satx.disa.mil. Newcontent has been added. Particularattention is called to the FAQ section,where you will find answers to questionsregarding MedTeams training andMonthly Summary Reports. Access pastcopies of the Patient Safety Bulletin, linkto patient safety resources and contactthe Patient Safety Program. Continue toreview the website for the latest informa-tion on DoD training.

PATIENT SAFETY IN ACTION

126th in action at Ryder Trauma Center

Leadership visit to the Neonatal Intensive Care Unit, NMCSD. Pictured:LCDR Con Lee Ying (Neonatologist), CAPT Charles B. Davis (DeputyCommander), CAPT Jon K. Thiringer (Chief Medical Officer), Mrs. AliceBontempo (Grandmother), Mrs. Linda Coleman (Mother), PatrickColeman (Patient)

Photos From Army and Navy

126th FST accepting trauma patient from AirRescue at Ryder Trauma Center


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7

SAN DIEGO

EXPANDS

WALKROUNDS

Leaders Walk and TalkPatient Safety

Naval Medical Center San Diego(NMCSD) has been holding lead-ership WalkRounds for nearly a yearnow, and is in the process of expandingthis practice into a source of data col-lection, analysis and patient safety deci-sion-making. Their experience pro-

vides an example of how DoD patientsafety providers are utilizing and adapt-

ing successful strategies from externalsources to enhance the culture of safety

within the military.

The WalkRounds concept derivesfrom a 2000 Institute for HealthcareImprovement (IHI) conference ofexperts called to envision characteris-tics of an ideal medication system.Recognizing that the strong commit-ment of senior leadership is a must inany system that truly encourages safety,

WalkRounds was conceived as aninformal method of connecting seniorleaders with providers. WalkRoundsis meant both to educate senior leader-ship about safety issues, and to signalleaderships commitment to creating aculture of safety. As it has developed inpartnership with IHI and the HealthResearch Educational Trust (HRET), theconcept has grown to include a relateddatabase for analysis of issues raisedduring rounds.

In September, 2003, CAPT J.K.Thiringer, DO, Director of ClinicalQuality/Chief Medical Officer, DR LindaSue Mangels, PhD, Pt Safety Specialist,and LCDR Linda Coleman, NC, PatientSafety Officer at NMCSD initiated thefirst trial of leadership rounds with thehospitals Executive Officer, CAPT C. B.

Davis, MC, USN. The rounds began asan informal attempt to provide leader-ship with hands-on involvement in thepatient safety effort at San Diego, toshow their level of concern aboutpatients and staff, and to give commandthe opportunity to dialogue directly withproviders. Recalling early visits to thefloor, LCDR Coleman describes initialstaff reticence soon giving way to activediscussion. A favorite ice-breakerquestion directed to staff was Whatkeeps you awake at night? As suggest-ed by the IHI tips on WalkRounds,leadership at San Diego focused onsafety issues and combined a format ofteaching and promoting open discus-sion, dialogue and identification of safe-ty issues specific to each unique envi-ronment.

Patient safety staff soon came to believethat the stories heard in the weeklyrounds sessions presented them with anuntapped source of important informa-tion. Over time, anecdotes suggestedtrends, different departments discussedcommon concerns, and staff recognizeda need to substantiate, analyze and acton what they were seeing and hearing.In March, 2004, with the addition ofCAPT P.A. Heim, NC to the hospitalpatient safety team, and the assistanceof CDR L. Axman, a nurse researcher,development of a more formal, system-atic rounds program was begun. Areview of the literature on

WalkRounds suggested that the mosteffective programs incorporate a quan-titative piece which allows them to clas-sify information according to contribut-ing factors and frequency and use theresulting priority score to determine

which issues are most in need of atten-tion. (Reference: Joint Commissionarticle, cited below.)

Leadership rounds at NMCSD are cur-rently evolving along this qualitativemodel. Rounds continue to be one houreach week, but discussions are now

transcribed and encoded into a soft-ware program. Safety related issuesare classified among six components

which influence clinical practice:organization and management; workenvironment; team; individual; task;patient. The resulting analysis will beused to identify trends and safety issues

which will be presented to the HospitalCommand to support requests for sys-tem-wide patient safety interventions.

To successfully take theirWalkRounds to this next level, lead-ership and patient safety staff at NMCSDhave invested a next level of time andattention. CAPT Heim credits the sup-port of the Senior Nurse Executive tosolicit volunteer coders and the assis-tance of the Command Research Deptto provide a nurse researcher as twocritical elements in their ability to trans-late information into data. Based onthe experience of other institutions,NMCSD expects their investment in

WalkRounds to yield practical as wellas symbolic results. Leadership at SanDiego walks and talks patient safety andcan now take even more informedaction to improve patient safety.

Contributors: CAPT J.K. Thiringer, MC,LCDR Lynda Coleman, NC, CAPT P.A.Heim, NC

Resources on WalkRounds:Institute for Healthcare Improvement.Patient Safety Leadership

WalkRounds; Conduct Patient SafetyLeadership WalkRoundswww.ihi.org/IHI/Topics/PatientSafety

Health Research & Educational Trust,Patient Safety Leadership

WalkRoundswww.hret.org/hret/programs/walkrounds.html

Joint Commission Journal on Qualityand Safety, January 2003, Vol. 29, No. 1Patient Safety Leadership

Walkrounds, Allan Frankel, MD, et al.

NAVY SUCCESSES IMPLEMENT LEADERSHIP MODEL


8/8

JCAHO PATIENTSAFETY NEWS

Alerts, Safety Goals, Quality Checks

Summer 2004 has been a busy time forthe Joint Commission on Accreditationof Healthcare Organizations (JCAHO). Thesethree important news releases are suggested

summer reading for all medical providers.Detailed information can be accessed on theJCAHO website at:www.jcaho.org.

2005 NATIONAL PATIENT SAFETY GOALSThe 2005 National Patient Safety Goals(NPSGs) were approved on July 9th.Application to individual accreditation pro-grams for each goal is specified. Additionalaction steps recommended for existingPatient Safety Goals include reporting criticaltest results and laboratory values to care-givers, and identifying look-alike/sound-alikedrugs and taking action to prevent relatederrors. New Goals for 2005 require accu-rately and completely reconciling medicationsacross the continuum of care; reducing therisk of patient harm resulting from falls;reducing the risk of influenza and pneumo-coccal disease in institutionalized olderadults; and reducing the risk of surgical fires.

SENTINEL EVENT ALERT: Preventing InfantDeath and Injury during DeliveryIssued on July 21, 2004, this sentinel eventalert is based on a total of 47 cases of perina-tal death or permanent disability that havebeen reported to JCAHO since 1996. Thealert identifies root causes (communicationissues were cited in a majority of cases), lists

risk reduction strategies, and offers JCAHOpractice recommendations. Organizations areencouraged to conduct team training toimprove communication, conduct clinicaldrills and debriefings for high-risk events,review and apply professional practice guide-lines, and utilize a standard maternal fetalrecord form for each admission.

QUALITY CHECKOn July 15, 2004 the Joint Commissionlaunched Quality Check, a website availableto the public, which reports health care information about the quality and safety of careprovided in its accredited organizations.Quality Check is intended to assist con-sumers in comparing local hospitals, homecare agencies, nursing homes, laboratoriesand ambulatory care organizations. It is alsodesigned to provide hospital-specific information about clinical performance in the care ofpatients with heart attacks, heart failure,pneumonia, and pregnancy. Consumers canaccess Quality Check at: www.quality-check.org.

8

PatientSafety

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 ProgramOffice of the Assistant Secretary of Defense (Health Affairs)

TRICARE Management ActivitySkyline 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 CenterArmed Forces Institute of Pathology

1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910Phone: 301-295-8115 Fax: 301-295-7217

E-Mail: [email protected] Website:http://patientsafety.ha.osd.milE-Mail to editor: [email protected]

DIVISION DIRECTOR, PATIENT SAFETY PROGRAM: CAPT Deborah McKayDIRECTOR, PATIENT SAFETY CENTER: Geoffrey Rake, M.D.

SERVICE REPRESENTATIVES:ARMY: LTC Steven Grimes

NAVY: Ms. Carmen BirkAIR FORCE: Lt Col Beth Kohsin

PATIENT SAFETY BULLETIN EDITOR: Phyllis M. Oetgen, JD, MSW

CONFERENCECALENDAR

3RD ANNUAL PATIENT SAFETY

RESEARCH CONFERENCE

September 26-28, 2004Crystal Gateway MarriottArlington, Virginiawww.ahrq.gov

ASHRM 2004 ANNUAL

CONFERENCE & EXHIBITION

October 18-20, 2004Orlando, Floridawww.ashrm.org

16TH ANNUAL NATIONAL

FORUM ON QUALITY

IMPROVEMENT IN HEALTH

CAREDecember 12-15, 2004Orlando, Floridawww.ihi.org

7TH ANNUAL PATIENT SAFETY

CONGRESS

May 5-9, 2005Orlando, Floridawww.npsf.org

TRANSFORMING MEDICATION

ERROR DATA INTOMEANINGFUL INFORMATION

One-day workshops offered by USP(CAPS)and Joint Commission ResourcesSeptember 22 - Rockville, Maryland

(USP Headquarters)November 1 - Oakbrook Terrace, Il

(JACHO Headquarters)December 4 - Orlandowww.jcrinc.com/education

psc newsletter 2004 summer

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