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fyou are involved in the DoD PatientSafety Program,you probably haveattended one ofthe multi-day trainingsessions offered by the Center for Educationand Research in Patient Safety (CERPS).Begun soon after the Patient Safety Programwas formally organized in 2001,these didac-tic experiences have evolved to include sepa-rate modules for introductory patient safety concepts and advanced training for patientsafety managers.Among the many topicscovered,the latest information on reportingto the Patient Safety Center is included,as isan introduction to TeamSTEPPS,the evi-dence-based teamwork training systemdeveloped by the Health Care Team Coordi-nation Program (HCTCP),a part ofthe DoDPatient Safety Program.For more informa-tion on all the curricula offered by the PatientSafety Program,or to review extensivepatient safety resources and helpful tools,access the CERPS website at:www.usuhs.mil/cerps/index.shtml.The integration ofeducation,teamwork,reporting,and reviewing and implementingbest practices is an important goal oftheDoD Patient Safety Program.In this Springissue ofthe Newsletter,we focus on twoaspects oftraining – TeamSTEPPS and thetraining Military Treatment Facilities per-form daily,as reported to the Patient Safety Center.One is a formal learning experience,the other a practical response to perceived orpotential safety concerns amongst caregivers.Both,however,are pieces ofthe larger whole– the DoD Patient Safety Program’s cycle of training and process improvement,an inte-grated effort in the service ofproviding asafer experience for our patients.
TeamSTEPPS….
Team Strategies and Tools to Enhance Performance and Patient Safety 
TeamSTEPPS is the comprehensive team-work training system designed to improvequality and safety in healthcare developed by the DoD Patient Safety Program in collabora-tion with the Agency for Healthcare Researchand Quality (AHRQ).It is comprised ofspe-cific key elements that include pre-trainingassessment and preparation,training of selected instructors,and a customizable planfor implementation and sustainment of teamwork performance across a department
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TeamSTEPPS Key Elements and Available Tools at a glance. From the TeamSTEPPSCourse Management Guide, TeamSTEPPS 06.1.
TeamSTEPPS PART OF DoD TRAINING FORIMPROVED PATIENT SAFETY
SPRING 2006A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
NEXT ISSUE:Results of DoD Patient Safety Culture Survey; Over 62,000 Responses Received
PSC: Training IsFirst Response
 
SPRING 2006
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Publication Renamed“Focused Review”
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Patient-Centered Aids
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Patient SafetyHits the News!
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•Initial site assessment•Leadership support•Observations•Culture Survey•Create a Change Team•Select Instructor Cadre•Select Executive Sponsor •Establishment of goals/metrics•SWOT analysis•Plan training•Grand rounds(multidisciplinary)•Communicationcampaign•Pre-training (baseline)survey•Set Aims•Train-the-Trainer –Fundamentals Course–Change Management–Coaching Workshop–ImplementationWorkshop–Practice TeachingSession–Train-the-Participant•Essentials Course•On-site support ofinitial training•Development of TeamImprovement Action Plan•Test Intervention•Track Aims•Communicate Updates•Monitor Plan•Ongoing Leadershipinvolvement–Executive sponsor updates•Continued Training–New staff–Refresher –In-service•Newcomers’ Orientation•Coach•Integration of team tools•Team PerformanceObservations•Post-training assessment•Metric results–reporting,analysis/reinforce•Web-based updates•Continuous Improvement
Key Elements and Available Tools
 AssessmentPlanning, Training& ImplementationSustainment
 
or facility.Within the last eighteen months,theDoD has established seven hundred (700)trainers/coaches ofteamwork principles inover thirty (30) Military Treatment Facilities(MTFs).These instructors have initiated train-ing at various levels to thousands ofMilitary Health System healthcare professionals.Aswell,teamwork competencies have been inte-grated into the program ofinstruction for pre-deployment training for forward surgicalteams as they prepare for battlefield healthcare.While not always part ofthe health care lex-icon,teamwork principles have becomeincreasingly recognized as integral to the effortto create a culture ofsafety in medicine.Theconnection between improved teamwork andfewer errors may seem intuitive,but healthcarehas traditionally been practiced as individualsilos rather than as a team endeavor.Other pro-fessions,however,have historically recognizedthe importance ofteams and team perform-ance.Research accumulated over the past sever-al decades in diverse areas such as aviation,nuclear power,military operations and indus-trial practice has provided a science ofteam-work – an evidence-based set ofcore compe-tencies with identified knowledge,skills andattitudes.Perhaps the most well-known exam-ple ofan effective teamwork strategy for reduc-ing errors is Crew Resource Management(CRM),the system adopted by the aviationindustry.Mandated by the Federal AviationAdministration since 1979,CRM emphasizesthe role ofhuman factors in high-stress,high-risk environments,and implements intense,focused communication,teamwork trainingand operations designed to increase safety.Therate ofU.S.airline fatalities has steadily declinedsince the adoption ofCRM;from 2001 throughDec.2005 there were no fatalities.Within the Department ofDefense,med-ical team training was mandated in theNational Defense Authorization Act of2001.This Act,which followed the Institute ofMed-icine report on medical errors,established thePatient Safety Program,and tasked theHealthcare Team Coordination Program withintegrating medical team training throughoutall healthcare operations.A multi-facility research project for Emergency Departmentsthat introduced teamwork training based onCRM captured notable decreases in observederrors and a subsequent increase in patientand staffsatisfaction.Positive outcomesresulted in the expansion ofmedical teamtraining to the specialty areas ofLabor andDelivery,Operating Room,Intensive CareUnit,Combat Medicine and “whole hospital”applications.TeamSTEPPS was developed toprovide a comprehensive unified curriculum,based on more than twenty years ofresearchon teams and team performance,for useamong all three Services.TeamSTEPPS provides an approach toteamwork training that imparts specific teach-able-learnable skills supporting team per-formance principles to include trainingrequirements,behavioral methods,humanfactors and cultural change designed toimprove quality and patient safety.This initia-tive is available to all MTFs.It is a stand-alonecurriculum,with multiple modules,designedto be implemented after a well-thought outplan over a timeline offive to nine months forfull implementation (varying with the size of the unit(s) trained).A critical threshold issuefor MTFs considering TeamSTEPPS trainingis their commitment to the process,as meas-ured by the requirement ofleadership buy-in.The success ofthis teamwork initiativedepends on strong leadership to communi-cate the vision,establish goal-oriented met-rics,and assign an executive sponsor and achange team.With the support ofleadership,the change team (along with staffat the sharpend ofcare) develops aTeam ImprovementAction Plan whichincludes training andimplementation ,andmeasures which are mon-itored over time.Coach-ing and mentoring on theunit or in the clinic havebeen identified as the key critical success factors.Actual TeamSTEPPStraining includes an ini-tial pre-training assess-ment ofthe MTF’s readi-ness,a training roll-outstrategy — in most casesusing a train-the-trainermodel — and continuedfollow-up and feedbackthrough consultation andparticipation in theLearning Action Network(LAN).The bi-monthly LAN is designed to createopportunities to share les-sons learned and bestpractices by networkingvia telephone with other
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SPRING 2006 PATIENT SAFETY
TeamSTEPPS Training 
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TeamSTEPPS “Shift Toward A Culture of Safety”. From the TeamSTEPPS Implementation Presentation.
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PATIENT SAFETY SPRING 2006
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Mary Ann Davis, RN, BSN, MSA
Nurse Risk Manager, Patient Safety Center 
T
he Patient Safety Center (PSC) usesthe data derived from the Monthly Summary Reports (MSRs) to providelessons learned and training suggestions tohealthcare providers.Information includedin the MSRs reflects the importance oftrain-ing on the Military Treatment Facility (MTF)level,as well.Staffis proactive in respondingto perceived problems.They provide trainingwithin their facilities,and their experiencescontribute to the general patient safety knowledge-base.This month,the PSC sharestraining lessons derived from your actionplans.The PSC receives monthly incidentreports and JCAHO reportable Root CauseAnalyses (RCAs) from MTFs all over theworld.Four years ago,when the PSC firstbegan to receive incident reports,the fore-most reaction to adverse events was to edu-cate and train the staff.This action still takesprecedence today.The type oftraining varies– from unit-specific exercises to departmen-tal reviews all the way to patient safety stand-downs,which encompass an entire facility.Whatever the mode or scope,staffeducationand training is universal among our MTFs.Itis the immediate and preferred action-stepwhen a patient safety issue arises.There are two areas that lately stand outin the MSRs as targets for increased staff attention.Code blue procedures and equip-ment utilization/familiarization particularly benefit from on-going,on-site trainingefforts.Your reports suggest that,in these twoinstances,fairly simple techniques,ifthey areconsistent and comprehensive,reap largepatient safety rewards.
Code Blue Procedures
R
eports to the PSC show that delays andconfusion when initiating codes orduring the code procedure sometimesoccur.This is especially true when codes arecalled in areas that have infrequent codeevents,such as the labor and delivery room.In these instances,staffmay have difficulty even locating the necessary equipment ormedication,and they may not know who ison call or how to contact them.Other code-related difficulties run a wide gamut:on-callresidents unfamiliar with treatment for aparticular patient;newly-assigned nurseswho lack adequate orientation;lack ofa des-ignated code leader;physicians who are hardto locate because the mode ofcommunica-tion is not dependable;overhead announce-ment systems too low to be heard;crash cartsthat are hard to locate or inadequately stocked.Since a code event is precipitated by a res-piratory or cardiac arrest,the response mustto be timely.MOCK CODES are the trainingtechnique ofchoice.They address both prac-tice and equipment deficiencies.Your reportstell us they are now being performed at regu-lar and frequent intervals in many MTFs -- atleast once a quarter,and on a rotational basisin low-density patient areas where a code isunlikely.Although some training related to acode event is classroom-based,drills are thekey to keep staffprepared and equipmentready.During a mock code,equipment canbe examined,replaced,ordered or repaired,eliminating the risk ofequipment absence orfailure in an actual emergency.Among the specific code training proce-dures reported to the PSC,the following aredirectly responsive to problems encountered.To maintain provider competence,residentsand nursing staffare being trained in neona-tal,pediatric and adult resuscitation,as wellas team communication.Code team mem-bers and patient care personnel are requiredto participate in two mock codes annually,and MTFs are adding code policies to theemployee orientation check-list.Rapid coderesponse is being addressed in a number of ways.One MTF has placed a chart namingthe designated code responders at the duty desk,ensuring universal accessibility (espe-cially for the weekend and night shifts) andtimely notification.Several facilities areusing cell phones within the hospital forcode contact.Code carts have been stockedwith standardized code equipment,includ-ing neonatal and pediatric resuscitationdevices,so time is not wasted when a code iscalled in these less anticipated areas.
Equipment Utilization
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quipment becomes a problem when staff is unfamiliar with the equipment’s func-tion,appearance,or proper utilization.Hospital and clinic staffs alike encounter a hostofequipment in their practice each day.They need to be familiar with each instrument ormachine as a working whole,as well as the dif-ferent parts ofeach machine.This is no smallchallenge in our technologically complexhealth care system.Safety issues based on problems withequipment can be simple or complex,but,whatever their origin,they have the potential tocause harm and even death.It is easy to mistakeone instrument for another when they lookalike.This is more likely when similar pieces of equipment are stored together,as they fre-quently are.Some equipment,by its nature,presents multiple opportunities for humanerror.The fetal monitor is a good example of such a device.Ifthe fetal monitor is incorrect-ly connected,it may record the mother’s heartrate,rather than that ofthe fetus.There is alsothe potential to misplace the monitor’s elec-trode;the alarm may be disconnected eitheraccidentally or on purpose;the fetal monitorstrip may be incorrectly read;and finally,themonitor itselfmay not be checked oftenenough to ensure proper functioning.Lack of familiarity with equipment can also contributeto an event.New or revised equipment usually includes improved but often repositionedswitches,alarms,connections or ports.Ifthedevice is used without first reading the manualor receiving instructions,the equipment may not function or may function incorrectly.When dealing with equipment,MTFsreport “JUST-IN-TIME”training as their pre-ferred action-step.However,to be effective,“just-in-time”training needs to be fully respon-sive to each element ofequipment utilization.Staffis usually told how equipment works,butis not always fully versed on why it is used,whathappens ifit fails,and when to report a prob-lem.“Just-in-time”training should be drilleddown in settings all around the hospital toinclude the following next level safeguards.Operating room staff,besides being familiar
TRAINING IS PART OFCULTURE OF SAFETYAMONG MTFs
Reports List Training As First Response To Adverse Events 
Feedback and Suggestions Based on Your Reporting 
NEWS FROM THE PATIENT SAFETY CENTER
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