INSIDE: Patient Safety Awareness Week Opportunities

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

TRI-SERVICE DENTAL
TRAINING A FIRST
Army Dental Command Organizes TeamSTEPPS Training

T 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-
Participants in Tri-Service dental TeamSTEPPS training make paper chains
as part of an ice-breaker exercise illustrating communication challenges.
“Most important to TeamSTEPPS for dental Pictured with civilian attendee are LT Thomas Atkin, HN Hargrove from
the Navy, and Army SPC Donald Knollenberg.
personnel is training by dentists who can ‘talk
dental’ to the audience” dental provider buy-in and leadership support – critical compo-
nents of TeamSTEPPS success no matter the setting or branch of
Roberta Sjelin, Nurse Consultant, Dental Patient Safety, MEDCOM PSC service. An added incentive for the tri-service attendees in Hawaii
was the provision of Continuing Education credit.
ing communication challenges during oral surgery and in a dental Interest in TeamSTEPPS among dental providers within the
office, and were trained by a team which included dental personnel DoD and beyond continues to increase. Plans are underway for
familiar with the TeamSTEPPS curriculum. more training in the U.S. and Europe this year. The Public Health
Adapting the TeamSTEPPS concepts, scenarios, tools and Service, the Institute of Healthcare Improvement and the Ameri-
trainers to the dental setting, Ms Sjelin believes, has brought more can Dental Association have all been in contact about the Army’s
validity to the training for its dental audience. It has also prompted unique dental adaptation of TeamSTEPPS.

TABLE OF CONTENTS 2 Dot-Mil-Doc 3 Mobile OB Simulator at 374 MDG 4 Reynolds ACH Shares HFMEA
 PATIENT SAFETY IN ACTION
Experience and Suggestions From Across the MHS

PENTAGON RADIO NETWORK FEATURES DOT-MIL-DOCS

Recent Episodes Highlight TeamSTEPPS Training In Theater
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.

PATIENT SAFETY PHOTO ALBUM

Patient Safety: All Day, Every Day Across the MHS
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.

2 WINTER 2009 Patient safety

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

Scott Chittenden, RN, HRM, MBA

Contract Patient Safety Program Manager

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 Dr. Lon Taff, MC, Maj, USAF introduces 374 MDG Family Care Unit Staff to MOES. Pictured left
that the simulator would be a creative to right are: Maj Cruz, Capt Evans, Lt Myers, Maj Roberts, Capt Fabre, SrA Badger, Capt Gomez,
response to the concern that up to forty Tsgt Johnson and Dr. Taff.
percent of maternal deaths in the United
States are potentially preventable and often Army Medical Center. Previous simula- methods for emergency deliveries, it will
related to obstetric care during emergen- tions (ACLS, PALS, OREs) have looked at promote and enhance our team perfor-
cies, as well as the related Joint Commis- either technical proficiency or teamwork, mance and communication.
sion requirement that emergency drills but rarely both of these key components Maj Lon Taff, M.D., Medical Director
become part of routine training. together to improve patient outcomes. The of OB services, and Maj Krisandra Smith,
It is well accepted that training on high- 374th MDG mobile OB project will incor- Surgical Specialty Flight Chief, are points
fidelity simulators improves pilots’ perfor- porate specific TeamSTEPPS skills into of contact for interested providers with OB
mance. The simulator-training concept was the MOES drills to combine individual and privileges and nurses interested in cross-
applied to DoD healthcare over five years team proficiency training in a unique way. training with the OB ward.
ago, beginning with efforts at Madigan Not only will this improve our teaching

Patient Safety: All Day, Every Day Across the MHS

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.

WINTER 2009 Patient safety 3

REYNOLDS ACH CONDUCTS PEDIATRIC HFMEA
Results Lead to Updated Policies and Tightened Security
Saundra Stinehart, MSN, CNS, APRN-BC
MAJ, AN, US Army Clinical Nurse Specialist,
Medical-Surgical-Pediatrics (PCU), ANCHEP
Coordinator
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.

4 WINTER 2009 Patient safety

PATIENT SAFETY REPORTING PROJECT
Testing and Limited Deployment Scheduled
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.

INFECTION PREVENTION WORKGROUP UPDATE

Workgroup Transitions to Infection Prevention and Control Panel
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.

WINTER 2009 Patient safety 5

PATIENT SAFETY AWARENESS WEEK
Annual Event Has Patient-Centered Focus
JOIN In Annual NPSF-Sponsored veloping safety culture
Patient-Centered Event competencies across
multiple heathcare pro-
The National Patient Safety Founda- fessions. He will share
tion (NPSF) is again inviting hospitals a comprehensive set of
and healthcare organizations around the best practices aimed at
country to join in Patient Safety Awareness improving the culture
Week, March 8-14. This national educa- of safety. Professor
tion and awareness-building campaign for Katherine Jones from
improving patient safety at the local level the University of
encourages events that educate patients Nebraska is an expert
on how to become involved in their own at analyzing culture
health care. The Week is also meant to survey results and
foster partnership activities between hospi- creating integrated
tals and their patient communities. team-based safety
Military Treatment Facilities (MTFs) solutions for change.
across the Military Health System have Together these two
a history of enthusiastically celebrating subject matter experts
Patient Safety Awareness Week. In year’s will help you learn
past, activities have included games like how to meet the 2009
patient safety Jeopardy and Poker, poster Joint Commission
contests, patient-centered displays and Leadership Standard
handouts, school visits, radio shows and for a culture of safety,
articles explaining patient safety. learn how to interpret
This year MTFs are again encouraged to your MHS Patient Safety Survey results, a short paragraph describing how your
observe Patient Safety Awareness Week. If and learn how to identify opportuni- facility marked the occasion, take photo-
you still need ideas or guidance you should ties and apply evidence-based tools for graphs of your activities, and send them
access the NPSF website at www.npsf. improvement in your facility. to the Patient Safety Newsletter for
org, and click the Patient Safety Aware- inclusion in our annual Spring Patient
ness Week link. A long list of activities for SHARE Your Experiences Safety Awareness Week review. Pictures
Patients and Families, as well as for Hospi- can be sent directly to the newsletter
tals, Healthcare Organizations and Staff is As you observe Patient Safety Aware- editor at poetgen@aol.com, or can be
available, as is the Patient Safety Awareness ness Week with patients and staff, we forwarded through your patient safety
Week logo download and a free Patient ask you to record your activities. Write service representative.
Safety Awareness Week Toolkit available to
Stand Up for Patient Safety members.
PATIENT SAFETY PROGRAM NEWSLETTER
LEARN With Special DoD PSP Published quarterly by the Department of Defense (DoD) Patient Safety DIVISION DIRECTOR,
Website Awareness Week Leader- Center to highlight the progress of the DoD Patient Safety Program. PATIENT SAFETY PROGRAM
ship Session DoD Patient Safety Program COL Steve Grimes
Office of the Assistant Secretary DIRECTOR, PATIENT SAFETY CENTER
As your facility celebrates Patient Safety of Defense (Health Affairs) Geoffrey Rake, MD
Awareness Week, leadership is encouraged TRICARE Management Activity DIRECTOR, CENTER FOR EDUCATION
AND RESEARCH IN PATIENT SAFETY
to access the Patient Safety Program web- Skyline 5, Suite 810, 5111 Leesburg Pike
Falls Church, Virginia 22041 Eric S. Marks, MD
site at http://dodpatientsafety.usuhs.mil 703-681-0064 DIRECTOR, HEALTHCARE TEAM
for an exciting learning opportunity. On Forward comments and suggestions to: COORDINATION PROGRAM
Wednesday, March 11, 2009 from 10:00 to Ms. Heidi King
DoD Patient Safety Center
11:00 am (EST) the DoD Learning Action Armed Forces Institute of Pathology SERVICE REPRESENTATIVES
1335 East West Highway, Suite 6-100 ARMY
Network will sponsor a Webinar entitled LTC Anthony Bohlin
Silver Spring, Maryland 20910
Creating a Culture of Patient Safety. This Phone: 301-295-7242 NAVY
special leadership session will be led by Toll free: 1-800-863-3263 Ms. Carmen Birk
speakers David Musson, MD and Kather- DSN: 295-7242 • Fax: 301-295-7217 AIR FORCE
E-Mail: patientsafety@afip.osd.mil Lt Col Anne Coyne
ine Jones, PT, PhD. Dr. Musson, profes- Website: http://dodpatientsafety.usuhs.mil
sor of Anesthesia at McMasters University E-Mail to editor: poetgen@aol.com PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
Phyllis M. Oetgen, JD, MSW
in Ontario, Canada has been active in de-

6 WINTER 2009 Patient safety