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PATIENT SAFETY HIGHLIGHTS FROM MHS CONFERENCE
WINTER 2008A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
INSIDE:Patient Safety Awards Supplement
2008 Tri-Service Survey Plans
WINTER 2008
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PSC Human Factors Corner
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Patient Safety Album
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Awards Presentation,Breakout Sessions Feature Patient Safety Activities 
Patient Safety Award Photos
Implementation of System Changes or Interventions22nd Medical Group, McConnell AFB, KSRuth M. Eckert, Chief, PerformanceImprovement, receiving Patient Safety Award from Dr. Smith, Dr. Jones and LtGen James G. Roudebush, Surgeon Gen-eral, USAF.
T
he 2007 Patient Safety Awards were formally presented atthe Military Health System (MHS) Conference in Wash-ington,D.C.The Conference,held January 28 through 31brought together MHS components and partners from aroundthe world for four days ofgeneral sessions with Executive Lead-ership,targeted breakout sessions,exhibitions and poster presen-tations.Especially exciting this year was a plenary session titled
Grand Rounds From the Front Line 
which linked commandersfrom remote,deployed locations in a virtual panel discussion of their challenges and successes,and a special screening of 
Fighting For Life 
,a new film interweaving stories ofmilitary doctors,nurs-es and medics and the wounded warriors they serve,(seewww.fightingforlifethemovie.comfor nation-wide screen datesand locations.)The traditional awards ceremony,held on Wednesday morning,featured Dr.Stephen L.Jones,DHA,Principal Deputy AssistantSecretary ofDefense (Health Affairs),Dr.Jack Smith,ActingDeputy Assistant Secretary ofDefense for Clinical and ProgramPolicy and Acting ChiefMedical Officer for TRICARE Manage-ment Activitiy,and each service Surgeon General presenting the2007 Patient Safety Awards to representatives ofthe recognizedfacility.Pictured at left are the official photos ofthe awardspresentation,courtesy ofAustin Camacho,Deputy Director,Public Affairs Office,TRICARE Management Activity.While the Patient Safety Awards presentation was the most dra-matic recognition ofthe importance ofsafety-related activitiesthroughout the MHS,patient safety efforts had a visible pres-ence in all ofthe various Conference venues.Several breakout sessions featured patient safety initiatives,many ofwhich have been publicized in the Patient Safety Newsletterover the past year.The Patient Safety Awards breakout sessionprovided a well-attended forum for presentation and discussionofthe five award-winning initiatives.Dr.Jack Smith,Acting
Use of TechnologyMadigan AMC, Tacoma, WADr. Smith, Dr. Jones and LTG Eric B.Schoomaker, Surgeon General, USA pre-sent Patient Safety Award to MAJ ShadDeering, Medical Director, Andersen Simu-lation Center.Implementation of System Changes or InterventionsUS Naval Hospital Sigonella, ItalyHospital Commander CAPT Helen V. Pearl-man, accepts Patient Safety Award from Dr.Smith, Dr. Jones and VADM Adam M.Robinson, Jr., Surgeon General, USN.Use of Technology49th Medical Group, Holloman AFB, NMLt Col Garry Feld receiving Patient Safety Award from Dr. Smith, Dr. Jones and LtGen James G. Roudebush, Surgeon Gen-eral, USAF.Improvements to Team Performance59th Medical Wing, Wilford Hall MC,Lackland AFB, TXCapt Jose L. Sanchez, NC accepts PatientSafety Award from Dr. Smith, Dr. Jones andLt Gen James G. Roudebush, SurgeonGeneral, USAF.
 
Deputy Assistant Secretary ofDefense forClinical and Program Policy and ActingChiefMedical Officer for TRICARE Man-agement Activity attended the breakout ses-sion.Dr.Smith congratulated all the presen-ters and the facilities they represented,andpresented each with a commemorative coinfrom the Office ofthe ChiefMedical Officerin recognition oftheir outstanding contribu-tions to patient safety.Below is a list ofthepatient safety-related breakout sessions:
Innovations In Patient Safety: 2008 Department ofDefense Patient Safety Awards 
(COL StevenGrimes,AN,USA and award recipients)
The Clinical Microsystem Framework: Its Impact on Process Improvement,with Practi-cal and Measurable Change 
(Eric S.Marks,MD;Diana Luan,PhD,MPA,MS)
Developing A Rapid Response Team: A Focus on Patient Care 
(LTC Eric Crawley,MC,USA)
TeamSTEPPS — Training Applications for Emergency Obstetrics and Forward Operating Surgical Team
(LTC Donald W.Robinson,MC,USA;MAJ Shad Deering,MC,USA)
TeamSTEPPS Training — Parts I and II 
(COL Sherry Ferguson,AN,USA;Dr.TimMcGuirk;Ms.Heidi B.King,MS,CHE)
Potential Use in the Military Health System — National Healthcare Safety Network (NHSN)
(CAPT Teresa C.Horan MPH,USPHS,CDC)Accesswww.health.milto see breakout ses-sions on-line.The Poster Exhibit included,as two ofits sixcategories,Quality and Effective PatientPartnerships,both ofwhich enhance theoverall safety ofpatients.Winning the cate-gory ofPatient Partnerships was a postersubmitted by Ms.Nancy Radebaugh of Darnall Army Medical Center,entitled
“Ambulatory Medication Reconciliation: APrescription for Partnership” 
.The posterdepicted the success ofthe wallet card writ-ten medication list patients carry at Dar-nall.The card is reviewed and updated at allmedical encounters,and its use ensurescommunication ofall therapies to thepatient care team.The DoD Patient Safety Program (PSP) andthe Healthcare Team Coordination Program(HCTCP) displayed their booths in the Exhi-bition Hall.New this year was the DentalPatient Safety Booth,a US Army DentalCommand initiative featured in the Fall 2007
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WINTER 2008 PATIENT SAFETY
PATIENT SAFETY CON-FERENCE HIGHLIGHTS
Continued from Page 1
CDR Tanya Ponder, NC, USN explains the Clinical Microsystems initia-tive submitted by US Naval Hospital, Sigonella at the Patient Safety Awards breakout session, MHS Conference.Presenters of the Patient Safety Awards initiatives pose following theMHS Conference breakout session with COL Steven Grimes, Director,DoD Patient Safety Program and Dr. Jack Smith, Acting Deputy Assis-tant Secretary of Defense for Clinical and Program Policy and ActingChief Medical Officer for TRICARE Management Activity. Pictured fromleft to right are: CAPT Jennifer Baker, Chief of Pharmacy, 49th MedicalGroup, Holloman AFB, NM; COL Grimes; Capt Jose L. Sanchez, NC,USAF, 59th Medical Wing, Wilford Hall MC, Lackland AFB, TX; Dr.Smith; Ruth Eckert, Chief, Performance Improvement, 22nd MedicalGroup, McConnell AFB, KS; MAJ Shad Derring, MC, USA, MedicalDirector, Andersen Simulation Center, Madigan AMC, Tacoma, WA. Award winning poster, submitted by Ms. Nancy Radebaugh, depictingthe Medication Reconciliation initiative at Darnall AMC, Ft. Hood, TX.DoD Patient Safety Program and HCTCP booths. Pictured are DianaLuan, PhD, RN, MPA, MS, Sr Research Policy Specialist CERPS and PaulHoerner, Lt Col USAF, BSC, Deputy Director, DoD Patient Safety Center.
 
P
lans for the deployment ofthe 2008DoD Tri-Service Survey on PatientSafety are underway.In 2005/2006,DoD deployed the first round ofthe survey to assess the culture ofpatient safety withinMilitary Health System (MHS) facilities.Until that time,limited tools to assess patientsafety culture had been available to DoD.The DoD Tri-Service Survey on Patient Safe-ty,sponsored and funded by TRICARE Man-agement Activity (TMA),is a web survey designed to assess staffopinions about issuesrelated to patient safety,medical errors,andevent reporting in the MHS.All staffworkingin Army,Navy,and Air Force Military Treat-ment Facilities (MTFs) and dental treatmentfacilities worldwide will be asked to completethis survey.Rollout is scheduled for March2008 with results available in September 2008.The survey assesses the following areas of patient safety in Military Health Systemfacilities:•Overall perceptions ofpatient safety •Frequency ofreporting events•Management support for patient safety •Supervisor/manager expectations &actions promoting patient safety •Organizational learning/continuousimprovement•Teamwork within work areas•Teamwork across work areas•Communication openness•Feedback/communication about error•Nonpunitive response to error•Staffing issues•Issues related to handoffs & transitionsGroup survey results will be reported at thefacility and Service levels,as well as the MHSoverall.Feedback comparing trends betweenthe 2005/2006 and 2008 survey results will beprovided.Strengths and areas for improve-ment will be identified.The results will helpthe DoD assess the status ofpatient safety improvement efforts within MHS facilities,raise staffawareness about patient safety,andmeet requirements ofthe Joint Commission.Results from the 2005/2006 survey were usedthroughout the MHS to help develop nextstep strategies to improve patient safety.Overall,53% ofall MHS staff(62,548respondents) completed the 2005/2006 sur-vey.Most respondents (80%) gave their workarea either an “A -Excellent”or a “B -Very Good”patient safety grade.Nine ofthe 12survey areas received a 50% or better positiveresponse;only 3 areas fell below 50%.
Teamwork Within Work Areas,Supervisor/ Manager Expectations and Actions Promoting Patient Safety,
and
Management Support for Patient Safety 
were considered strengths.Areas for improvement included
Handoffs and Transitions,Staffing,Nonpunitive Response to Error,
and
Number ofEvents Reported 
.Detailed results from the 2005/2006 survey were published in the Summer2006 issue ofthe Patient Safety ProgramNewsletter.The success ofthe upcoming March 2008survey depends on the participation ofallMHS staff.Please contribute to the results by participating in the survey.For any questionsor comments,please contact Mr.MichaelDatena (RPh),DoD Patient Safety Program,atmichael.datena@tma.osd.mil.
PATIENT SAFETY WINTER 2008
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Spring Rollout Planned for Web-based Assessment Tool 
DoD 2008 TRI-SERVICE SURVEY ON PATIENT SAFETY
"The DoD Patient Safety Program is dedicated to improving patient safety across the Military Health System (MHS).After the 2001 official launch ofthe DoD Patient Safety Program,the 2005 survey provided a first-time assessment ofthe safety culture within the MHS.We aim to learn from the 2005 and 2008 survey results,making comparisons where appropriate,to enable open discussions regarding the culture ofsafety inour system and how we can continuously work together to further improve it." 
—Jack Smith, MD, MMM Acting Deputy Assistant Secretary of Defense for Clinical and Program Policy United States Department of Defense Military Health SystemJanuary 2008
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