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Improvements to Team Performance
59th Medical Wing,Wilford Hall Medical Center,Lackland AFB,TX 
Title: Nurse/Mental Health TechnicianChange ofShift Safety Checks 
The mental health unit team at WilfordHall Medical Center implemented a simplebut effective schedule of“safety checks”toreduce the likelihood ofpatient self-harm orsuicide.Responding to the reality that suicideis the second most frequently reported sen-tinel event nationwide,the Wilford Hall teamrecognized that their current safety protocolscould be reviewed and strengthened.The team developed a structured safety check process designed to prevent patientself-harm or suicide by ensuring thatharmful objects are identified andremoved.The safety check is performed by a nurse and mental health technician ateach shift change.Any hazards or findingsare immediately corrected and are commu-nicated to the incoming team.Data collected over six months oftrack-ing the safety checks indicated that poten-tial hazards,easily accessible to at-riskpatients,did exist and.With each successivemonth ofsafety checks,however,fewerhazards were identified.Over the initial sixmonth period ofdata collection,there wasa seventy-five per cent (75%) reduction inthe number ofhazards found.Providers in the Wilford Hall mentalhealth unit have created a safer environmentfor their at-risk patients.By standardizingthe safety check process they have addresseda perceived patient need;by utilizing a teamapproach they have assumed joint responsi-bility for the safety oftheir patients.
Implementation of SystemChanges or Interventions
22nd Medical Group,McConnell AFB,KS 
Title: Revision ofthe Medication Renewal Process 
The 22nd Medical Group designed analternative process for responding to med-ication renewal calls which improved bothefficiency and the quality offollow-up carefor patients.Concerned that nurses were spendingtoo much duty time dealing with requestsfor medication renewal,a team was formedto find a better way to field calls.Theiranswer was consolidation ofcalls to a ded-icated renewal line,open twenty-fourhours a day,seven days a week.Technicianswere specially selected and trained to
2007 PATIENT SAFETY AWARDS
JANUARY / FEBRUARY 2008A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
SPECIAL SUPPLEMENT — 2008 MHS CONFERENCE
Continued on Back
T
he tradition ofinnovation,improvement and excellence in the service ofpatient safety continues across the Military Health System(MHS).For the fifth year,the MHS Conference,scheduled for January 28–31 in Washington,D.C.will provide a system-wide venuefor the presentation ofthe Department ofDefense (DoD) Patient Safety Awards.These awards are an annual,public recognitionofthe day-to-day,ongoing efforts by military healthcare providers to create a culture ofsafety and quality within the MHS in response tothe stated commitment ofthe DoD and the Patient Safety Program (PSP).The focus ofthe 2008 MHS Conference is the MHS Strategic Plan.All conference presentations align with the plan’s goals and objectives,many ofwhich include actions steps aimed at achieving evidence-based healthcare,patient-centered care,and quality in all aspects of healthcare delivery.In keeping with the Conference focus,the 2007 Patient Safety Awards have honed in,as well,on initiatives that facili-tate better meeting the needs ofour patients.The 2007 DoD Patient Safety Awards formally recognize efforts designed to improve the care delivered within the Military Health System.The awards celebrate those who have shown innovation and commitment to the development ofsystems and processes that are tightly organized around the needs ofthe patient.Categories for consideration include:Improvements to team performance;Use oftechnology to improve patient safety;Implementation ofsystem changes or interventions to improve patient safety and or meet national patient safe-ty standards.By presenting these awards,DoD seeks to highlight and encourage efforts that create an environment where safe,quality careis provided and is acknowledged as the responsibility ofall members ofthe team.Recipients ofthe 2007 Patient Safety Awards are:
• 59th Medical Wing — Wilford Hall Medical Center — Lackland AFB,TX 
(Improvements to Team Performance)
• 22nd Medical Group — McConnell AFB,KS
(Implementation ofSystem Changes or Interventions)
• US Naval Hospital Sigonella — Scicily,Italy 
(Implementation ofSystem Changes or Interventions)
• 49th Medical Group — Holloman AFB,NM
(Use ofTechnology)
• Madigan Army Medical Center — Tacoma,WA
(Use ofTechnology)
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