INSIDE: Patient Safety Center Information Page 2

Patient SPRING 2003

F0011
Page 2 Eisenberg Award Link

Safety
Page 3 Pharmacy Photos
Page 4 DoD Training Dates
Page 4 Message from CAPT McKay

A quarterly newsletter to assist DoD hospitals with improving patient safety

NATIONAL NAVAL MEDICAL CENTER
AUTOMATES PHARMACY
Total System Change Improves Safety
T he Pharmacy at the National Naval
Medical Center recently imple-
mented an automated system which
pharmacy. Although robotics has
received the lion's share of attention,
hardware addresses only the filling of
points of human decision-making.
Second, rather than printing the pre-
scription label first, as is common in
puts it on the cutting edge of patient prescriptions. The enhanced integrated most pharmacies, the new system only
safety and efficiency. After being award- software now being used at Bethesda prints the label after the correct drug
ed a contract in March 2002, McKesson and NH Jacksonville includes, but goes and dosage has been verified and is in
APS worked with teams from Naval well beyond, robotics. It makes possi- hand.
Hospital Jacksonville and National Naval ble two key changes directly responsi-
Medical Center to enhance the compa- ble for reducing human errors. First, The following flow chart illustrates the
ny's existing pharmacy software. Their across the entire prescription filling enhanced decision support afforded by
goal was to design an integrated and process, the software and hardware uti- the software in almost every step in the
scalable solution that could meet the lizes barcode technology to provide ver- new prescription filling process. Each
needs of both the smallest and the ification of activity, enhancing most red box represents a decision point in
largest Navy pharmacy. The software Continued on page 3
ties together both new and refill pre-
scription processing utilizing touch
screens, digital counting scales, and
robotics. This advanced technology
provides decision support at each step
in the filling process minimizing human
intervention and reducing errors.
Bethesda is the first facility to fully
implement the new system, with NH
Jacksonville close behind. Preliminary
data suggest that errors have fallen dra-
matically.

According to CDR W.H. Blanche, the

Pharmacy Department Head at
Bethesda, software is the critical ele-
ment in ensuring patient safety in the
NEWS FROM THE
PATIENT SAFETY
CENTER
Feedback and Suggestions
Based on Your Reporting
A new feature of the Newsletter,
News from the Patient Safety
Center will contain the latest feedback,
suggestions, action plans and instruc-
tions from the Patient Safety Center. You
are invited to contact the staff of the
Patient Safety Center with issues which
you would like to see addressed here.
REPORTS PROVIDE
LESSONS LEARNED
Three Strategies Reduce Risk of
Treatment Delay
The Patient Safety Center at AFIP receives
root cause analyses (RCAs) and monthly
summary reports from Medical Treatment
Facilities (MTFs) within the three servic-
es. Under the Deparment of Defense
Instruction number 6025.17, the Military
Health System Patient Safety Registry
(MHSPSR) reviews and analyzes these
reports. The MHSPSR has received
monthly summary reports from MTFs for
over six months. Quarterly reports have
been produced from the reports submit-
ted.
Delay in treatment or diagnosis was
found to be one of the top events report-
ed to the MHSPSR. JCAHO also sites
delay in treatment in its top five most fre-
quently reported sentinel events. The
RCAs submitted to MHSPSR with an event
related to a delay in treatment share simi-
lar lessons learned. We have listed below
the three most three significant areas of
lessons learned, and we encourage each
MTF to review these and ensure they are
part of your routine practice guidelines.
Communication:
Use timely and efficient communication
for network provider and consultants.
Communicate throughout all levels of
command.
Be thorough and specific when commu-
nicating changes in a patient's condition.
Use verbal feedback to assess under-
standing of communication.
Documentation:
Check orders in patient's chart and com-
plete all documentation.
Obtain and document a thorough med-
ical history.
Do not accept a verbal order when a
written order should be obtained.
Training:
Provide thorough and unit specific ori-
entation and training for staff.
Educate staff on standard protocols.
Implement team training.
FACILITIES ACT TO
IMPROVE PATIENT
SAFETY
Reports Describe Education and
Training Efforts in MTFs
On the Monthly Summary Report, the
Military Health System Patient Safety
Registry (MHSPSR) asks for a brief
description of one or more safety actions
to improve patient safety within each
MTF. Education and training was the
focus of the action plans in the monthly
summary reports submitted to the MHSP-
SR last quarter.
Across the services, MTFs are conducting
mandatory safety training. These training
sessions are meant to heighten staff
awareness of the importance of patient
safety. Some facilities conducted all day
comprehensive training on performance
improvement and patient safety. Other
facilities planned four-hour training ses-
sions that included patient safety, security,
facility safety, back safety and numerous
other safety related areas.
In addition to the training sessions noted
above, the MTF actions have included
poster displays with general patient safety
information placed in examining rooms,
posters for the staff indicating the type of
safety events to report and why, and
posters with Patient Safety Goals.
2
Patient Safety Links
Interesting Resources To Explore
John M Eisenberg 2003 Patient Safety
Awards
www.jcaho.org
Recognize individuals and organizations that
have made significant contributions to
patient safety. Nomination deadline: May
27, 2003
Quality HealthCare.org
www.Qualityhealthcare.org
A new "global knowledge environment"
sponsored by IHI and BMJ Publishing Group.
Created to accelerate improvement and per-
formance; includes patient safety section.
FDA Patient Safety News
www.fda.gov/cdrh/psn
A monthly patient safety broadcast,
accessed via the web. April issue includes
articles and links on a number of safety top-
ics including preventing errors in children
and safe use of drugs that end in "L".
United States Pharmacopeia
www.usp.org
Summary of Information Submitted to MED-
MARX in the Year 2001: A Human Factors
Approach to Medication Errors. Third annual
report and analysis; a comprehensive compi-
lation of medication error data.
Patient Safety First
www.patientsafetyfirst.org
Part of AORN (Association of periOperative
Registered Nurses) broader patient safety
initiative. Click on Information Resources
for many informative links.
One MTF is using email as a rapid cycle
performance improvement technique to
train staff. Department heads and staff
are emailed information on the patient
safety program and goals. The safety
emails lead to discussions with depart-
ment heads and initiate education within
the departments. Another MTF has start-
ed an employee hints email as a weekly
patient safety tool. Each week the email
covers different safety issues. This was
developed as a concise and efficient way
of sharing safety information with the
staff.
Patient safety handouts are also being
distributed to staff and patients. A tri-fold
pamphlet has been developed to help the
staff understand near misses, sentinel
events and the importance of reporting,
how to report and who to contact.
If your Facility has tools or brochures
you would like to share send them to:
DoD Patient Safety Center, 1335 East West
Hwy., Ste 6-100, Silver Spring MD 20910
or email us at: patientsafety @
afip.osd.mil.
Patient Safety
In Action
Experiences and suggestions
from the field
Continued from page 1
the old process where human error
could be introduced. The new automa-
tion process has dramatically reduced
these red blocks and replaced them
with decision support provided by the
software and hardware.
Under the automated system, there is
only one point where some type of sup-
port is not provided to the technician or
pharmacist. This occurs when civilian
prescriptions must be interpreted and
entered into the CHCS computer system.
However, the automation captures a
picture of each civilian prescription and
displays that image throughout the
remainder of the filling process. This
image is also displayed when prescrip-
tions are refilled allowing continued
validation of the proper medication.
With barcode technology driving the
process, the technician scans the
patient's ID, selects the medication to
be filled, and is directed by the comput-
er to the medication's location in the
pharmacy. If the medication is located
in an automated counting device, the
software automatically counts the med-
ication. For those medications not in
counting devices, the technician scans
the manufacturer's drug barcode to
confirm that the correct medication has
been selected. If correct, a blue screen
appears and the prescription label is
printed. If the wrong medication was
selected, a red screen appears warning
the technician of a possible error. Only
when the correct medication is identi-
fied will a prescription label be printed.
As a final check the pharmacist scans
the barcode printed on the prescription
label. The software retrieves all vital
information for that prescription. This
includes a picture of the prescription if
written by a civilian physician and a pic-
ture of what the capsule/tablet or con-
tainer should look like. The pharma-
cist scans her personal barcode to sig-
nify when each prescription has been
checked.
Redesigned pharmacy patient window at
Bethesda.
To ensure the most efficient use of the
new system, even the physical space of
the Bethesda pharmacy underwent a
redesign. Despite the inconvenience,
changes and learning curve faced by the
pharmacy staff, the automated process
has been enthusiastically embraced.
Support from leadership has set the
tone. Most importantly, CDR Blanche
reports, everyone in the pharmacy feels
the new technology provides the safest
environment possible.
The experience at Bethesda and
Jacksonville provides a model for other
facilities interested in improving their
pharmacy delivery systems. The Navy
development team had a vision of how
the pharmacy could work more effi-
ciently and found a vendor willing to
support that vision. By pooling
3
resources and working closely with
Naval Medical Logistics Command, that
vision is now a reality.
Pharmacy technician H.N. Bermudez scans
label into automated system.
This major change to the existing deliv-
ery system was possible only with the
leadership of a dedicated team who
worked on the enhancements for a full
year. Credit goes to: CDR Blanche,
LCDR Dave Hardy, LT Jody Dreyer and
LT Joe Lawrence. Credit also is due the
entire staff of the Bethesda Pharmacy
whose willingness to pilot the new soft-
ware and hardware will make future
implementations much easier. They are
the true leaders in patient safety.
For additional information, contact the
Bethesda pharmacy at: 301-295-2113
or email CDR William D. Sanders:
wdsanders@bethesda.med.navy.mil
Does your facility have a cre-
ative approach to spreading
the message of patient safety?
You are invited to send a short
description of your patient
safety initiative to the Editor
so that it can be shared in the
next Newsletter. Send copy to
Editor: poetgen@aol.com.
MESSAGE FROM
CAPT MCKAY
DOD PSProgram Addresses
Nosocomial Infections
A ccording to the CDC, each year
nearly two million patients in the
United States get an infection in a hospi-
In response to the impending JCAHO
changes and to increase safety in
Military Treatment Facilities, the DoD
Patient Safety Program is taking meas-
ures to assist MTF's in combating noso-
comial infections. We have joined the
CDC Campaign to Prevent Antimicrobial
Resistance in Healthcare Settings. The
goals of the Campaign are threefold: to
near future.
If you have suggestions for DoD
Campaigns and/or initiatives aimed at
decreasing nosocomial infections,
please contact CAPT McKay, the DoD
Patient Safety Program Manager, at deb-
orah.mckay@tma.osd.mil

tal, and about 90,000 die as a result.
Additionally, more than seventy percent
of the bacteria that cause hospital-
acquired infections are resistant to at
least one of the drugs most commonly
used to treat them.
JCAHO president Dennis O'Leary M.D.
recently stated, "Infection control is a
critical component of safe, quality
health care". An expert panel met to
recommend enhancements to existing
standards and to suggest ways in which
the Joint Commission can better ensure
increase awareness of the problem of
antimicrobial resistance in healthcare
settings; to implement the campaign's
four strategies to prevent antimicrobial
resistance; and to prevent antimicrobial
resistance in healthcare settings. The
website, accessible at www.cdc.gov,
offers tools for clinicians to raise aware-
ness and to decrease the chances of
nosocomial infections. The DoD Patient
Safety Committee is also planning is to
partner with existing DoD Infection
Control activities and initiatives in the
Editor's Note: The Sentinel Event Alert
on infection control issued by the Joint
Commission on January 22, 2003
(www.jcaho.org) reports that cases of
deaths relating to infection are seriously
under-reported, but they do meet the
criteria for reviewable sentinel events.
The Alert identifies root causes and risk
reduction strategies, and recommends
that facilities comply with the CDC's new
hand hygiene guidelines.

Patient
that accredited organizations are
addressing the problem of nosocomial
infections. The panel's findings resulted
in new JCAHO infection standards, to be
introduced in 2004.
Safety
Patient Safety is published by the Department of Defense (DoD) Patient Safety Center,

CONFERENCE located at the Armed Forces Institute of Pathology (AFIP). This quarterly bulletin provides periodic updates
on the progress of the DoD Patient Safety Program.

CALENDAR DoD Patient Safety Program

Office of the Assistant Secretary of Defense (Health Affairs)
TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, Virginia 22041
DOD PATIENT SAFETY TRAINING 703-681-0064

May 13-16, 2003

San Antonio, Texas Please forward comments and suggestions to the editor at:
www.afip.org/PSC DoD Patient Safety Center
Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
VIRGINIANS IMPROVING PATIENT Phone: 301-295-8115 • Fax: 301-295-7217
CARE & SAFETY E-Mail: patientsafety@afip.osd.mil • Website:www.afip.org/PSC
E-Mail to editor: poetgen@aol.com
Advancing Patient Safety & Quality:
Integrating Technology, Communications DIVISION DIRECTOR, PATIENT SAFETY PROGRAM: CAPT Deborah McKay
and Best Practices ACTING DIRECTOR, PATIENT SAFETY CENTER: Gaetano F. Molinari, MD, MPH
SERVICE REPRESENTATIVES:
May 15, 2003 ARMY: Col. Judith Powers, AN
Richmond, Virginia NAVY: Ms. Carmen Birk
www.vipcs.org or 804-643-6631 AIR FORCE: Lt. Col. Beth Koshin
Lt. Col. Cynthia Landrum-Tsu
PATIENT SAFETY BULLETIN EDITOR: Phyllis M. Oetgen, JD, MSW