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SPRING 2009A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
INSIDE:Patient Safety Awareness Week Insert
HEIDI KING RECEIVES
NATIONAL PATIENT SAFETY FOUNDATION
CHAIRMAN’S MEDAL
s. Heidi King, Director, Department of Defense(DoD) Healthcare Team Coordination Programsince 2002 and currently Acting Director, DoDPatient Safety Program received the prestigious NationalSafety Foundation Chairman’s Medal on May 21, 2009.Presented at a special ceremony during the National PatientSafety Foundation (NPSF) Annual Congress, the medal
recognizes emerging leadership in the eld of patient safety.
It is awarded to an individual who has demonstrated theability to inspire, to lead and to effectuate measurable posi-tive change and improvement within a culture of respect,openness, learning and team dynamic.Ms. King’s visionary, motivational leadership and relent-less determination to accelerate widespread improvementsin patient safety have resulted in several DoD-led outreachand collaborative efforts, most notably the internationally successful TeamSTEPPS program, developed by the DoDin partnership with the Agency for Healthcare Research andQuality (AHRQ). Pamela Austin Thompson, RN, MSN,FAAN, Chair of the NPSF Board, described the Chairman’sMedal as the “highest award” bestowed by the Foundation.In her presentation remarks, she recognized Ms. King as an“innovator whose work has had a far-reaching impact on the
eld of patient safety”.
 The many DoD leaders and providers who have workedunder Ms. King’s leadership as TeamSTEPPS champions,trainers and practitioners readily attest to her inspiration,tenacity and passionate personal commitment. It is withgreat pride that all involved in the important DoD missionof keeping our patients safe say CONGRATULATIONSto Ms King for her well-deserved national recognition, and THANK YOU to a leader of uncommon vision and skill.
National Award Recognizes Leadership In Patient Saety
 
M
Heidi King, Acting Director, DoD Patient Safety Program, receives NationalPatient Safety Foundation (NPSF) Chairman’s Medal from NPSF Board ChairPamela Austin Thompson, RN, MS, FAAN (middle). With them, left to rightare former NPSF board chairs Paul Gluck, MD; Carol Ley, MD, MPH; Timothy Flaherty, MD. Photo taken by Event Digital Photography, Inc.
TABLE OF CONTENTS
 
5
Fall Conerence Highlights
6
PSP News
8
TRICARE Patient Saety Month
 
NATIONAL PATIENT SAFETY FOUNDATION CONGRESS HIGHLIGHTS
DoD Providers Attend Congress, Award Presentation Culminates Busy Day2
SPRING 2009 PatIeNt Safety
HEIDI KING ACCEPTS AWARD
 The NPSF Chairman’s Medal was presentedat the Lucian Leape Institute Town Hall Plenary. A panel of nationally acclaimedpatient safety leaders witnessed the award ceremony: Paul O’Neill, former Treasury Secretary; Dennis O’Leary MD, Pres. Emeritus, The Joint Commission; Julianne
M. Morath, RN, MS, Chief Quality and Safety Ofcer, Vanderbuilt Medical Center;
 James A Guest, Pres., Consumers Union; Lucian Leape, MD, Harvard School of Public Health; Janet Corrigan, PhD, MBA, Pres. & CEO, National Quality Forum;Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality;David Lawrence, MD, Kaiser Foundation Health Plan, Inc.; Donald M. Berwich,MD, MPP, Pres & CEO, Institute for Healthcare Improvement. In accepting theChairman’s Award, Ms. King recognized the many dedicated providers from DoDfacilities. She told the NPSF audience:
“This would not be possible without our dedicated team working in the Department of Defense 
Patient Safety Program and those in the eld on the frontlines of care… We are energized by the success stories we hear from our providers in the eld on how they are preventing medical errors, stop
- 
 ping them before they reach the patient. “We all play a vital role…If you are a care provider, make every patient visit count by empowering your patients to become informed, active participants on their care team. Leaders, renew your commitment to enable our most valuable asset — our people — to provide safe care in a learning environment where they may openly communicate, work together, and 
learn from their mistakes so that no other patient will be harmed from the same error.” 
MHS LEADERSHIP CONGRATULATES AWARD RECIPIENT
HeidiKing, Acting Director, DoD Patient Safety Program, poses at the National PatientSafety Foundation Congress with COL James Black, Senior Medical Director, TMA,and Jack Smith, MD, MMM, Acting Deputy Secretary of Defense for Clinical Policy and Programs. COL Black shared these congratulatory comments:
It is my great pleasure to congratulate Heidi on being awarded the National Patient Safety Foundation Chairman’s medal. She has inspired countless providers, nurses, and other healthcare 
team members to embrace and execute TeamSTEPPS. The visible results of her efforts and the out- 
 pouring of positive and thankful comments from those in the eld is a testament to her extraordinary 
achievements.
DOD PROVIDERS ATTEND NPSF CONFERENCE
 A large contingent of DoD patient safety staff from across the Military Health System attended the Na-tional Patient Safety Foundation Congress. Patient Safety Managers Scott Chitten-
den, Yokota AFB and Marcia Vondran Lutz, Mountain Home AFB talked about the
Conference and TeamSTEPPS. Scott Chittenden found that patient safety expertLucian Leape’s comments resonated with his experience: “Dr. Leape said that thetwo most important things necessary to reform healthcare are teamwork and theresources to implement it. We’ve found at Yokota medical care is at its best when the
team is complete”. Vondran Lutz says that providers at Mountain Home AFB nd
 TeamSTEPPS “very valuable”. They have enhanced their experience by adding theDoD HFACS human factors component to their program, which they believe hashelped reduce same event errors.
 
ne year ago TeamSTEPPS wassuccessfully introduced to the 86thCombat Support Hospital (CSH)in Baghdad. In late November 2008, with the support of the Patient Safety Program’s Healthcare Team Coordina-tion Program (HCTCP), TeamSTEPPS was expanded to 10th CSH as part of the overall plan to utilize TeamSTEPPSthroughout the combat theater. Over1,000 military medical personnel serv-ing in Iraq are currently TeamSTEPPS
trained. Now just one year after it rst
 went to war, TeamSTEPPS is an integral, widespread part of the acute medical careavailable to our wounded warriors.Like their counterparts at the 86thCSH, providers from the 10th CSH areenthusiastic in their embrace of Team-STEPPS. The successes they sharebelow are examples of TeamSTEPPSprinciples at work in the midst of thechaos and challenges of combat. Utiliz-ing varied techniques, the theme is thesame –TeamSTEPPS training empowersstaff of every level and discipline to act
as a seamless unit for the benet of the
patients they share.
SITUATION MONITORING
 A Lifesaving TeamSTEPPS Lesson
 TeamSTEPPS teaches providers toreduce error by continually scanning andassessing what is going on around them,ensuring that changes are quickly caught. Team members monitor each other’sactions and provide a mutual safety net within the team.Constant situation awareness by teammembers at the 10th CSH ensures thatany rapid and unpredictable deteriorationin the status of their patients is readily observed, assessed and treated. In thecombat environment this TeamSTEEPStool has proven to be a particularly criti-cal asset, as so many patients suffer fromcomplex trauma injuries which increasethe likelihood of unexpected changes.Providers from the 10th CSH report thatall team members feel empowered by  TeamSTEPPS to assess potentially life-threatening situations and take appropri-ate action to keep patients safe. With itsshared focus on timely intervention andcollective responsibility, this Team-STEPPS tool has allowed team membersno matter their rank or specialty to en-gage and react, resulting in good catchesand saved lives at the 10th CSH.
HANDOFF and SBARCOMMUNICATION TOOLS
 What You Don’t Know Can Hurt Your Patient
 TeamSTEPPS places a high priority oncommunication and provides a variety of tools to ensure that patient information iscommunicated among providers. During transitions of care, the HANDOFF sendscritical information along with the patientso that safety is not compromised because
signicant facts are unknown. While car
-ing for a patient, providers are taught toclearly and succinctly share actionable in-formation using the SBAR technique – adescription of the Situation, Background, Assessment and Recommendation.In combat support hospitals likethe 10th CSH, host nation patients arefrequently treated. In addition to theirexpected complex medical conditions,these patients represent a diversity of languages and cultures which often pres-ent additional communication challenges. Team members from the 10th CSHreport that the TeamSTEPPS Handoff and SBAR tools have been especially useful to them in caring for host nationpatients. These techniques have enabledproviders to quickly recognize incom-
plete reports from the eld, perform
more systematic patient assessments, andidentify patients with critical conditionsthat warrant higher levels of care. Staff 
are condent that use of these structured
 TeamSTEPPS tools has mitigated com-
munication difculties, further prevent
-ing patient harm and saving the lives of host nation patients. 
THE HUDDLE
 The Team that Huddles Together Helps Together
 TeamSTEPPS empowers each teammember to speak up, challenge and lead when appropriate. The HUDDLE, anad hoc problem solving technique, al-lows team members to reassess, rein-force, or readjust plans as necessary toassure the safety of their patient. Team members from the 10th CSH re-port that, in the dynamic arena of combatmedicine, the huddle is an ideal way toreassess changing patient care conditionsand problem solve to provide the mostappropriate care. Transporting patientsfrom combat support hospitals to otherlevels of care is a continuing necessity and an on-going challenge. Transporta-tion plans may need to be changed on thetarmac if a patient’s condition deterio-rates or a medevac helicopter or civilianair ambulance lacks specialized equip-ment. Teams from the 10th CSH rely onthe huddle throughout the transportationprocess. They take a time-out on thespot to redirect or reprioritize transporta-tion plans when this is indicated, assur-ing that patients are provided the safestlevel of care from the time they arrive atthe 10th CSH to the moment they leave.For over a year now TeamSTEPPShas been utilized in the theater of opera-tions. These successes from the 10thCSH tell a tale of provider dedicationand enhanced patient care. They send aclear message that TeamSTEPPS is help-ing to keep our patients in the combatzone safe from additional harm.
TEAMSTEPPS: A COMBAT VETERAN
10
th
Combat Support Hospital Adopts TeamSTEPPS; Shares Successes
SPRING 2009 PatIeNt Safety
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