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SPECIAL SUPPLEMENT — 2008 MHS CONFERENCE

JANUARY / FEBRUARY 2008 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

2007 PATIENT SAFETY AWARDS


T
he tradition of innovation, improvement and excellence in the service of patient 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 venue
for the presentation of the Department of Defense (DoD) Patient Safety Awards. These awards are an annual, public recognition
of the day-to-day, ongoing efforts by military healthcare providers to create a culture of safety and quality within the MHS in response to
the stated commitment of the DoD and the Patient Safety Program (PSP).

The focus of the 2008 MHS Conference is the MHS Strategic Plan. All conference presentations align with the plan’s goals and objectives,
many of which 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 of our 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 of systems and processes that are tightly
organized around the needs of the patient. Categories for consideration include: Improvements to team performance; Use of technology
to improve patient safety; Implementation of system 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 care
is provided and is acknowledged as the responsibility of all members of the team.

Recipients of the 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 of System Changes or Interventions)
• US Naval Hospital Sigonella — Scicily, Italy (Implementation of System Changes or Interventions)
• 49th Medical Group — Holloman AFB, NM (Use of Technology)
• Madigan Army Medical Center — Tacoma, WA (Use of Technology)

Improvements to Team Performance a nurse and mental health technician at Implementation of System
59th Medical Wing, Wilford Hall each shift change. Any hazards or findings Changes or Interventions
Medical Center, Lackland AFB, TX are immediately corrected and are commu- 22nd Medical Group, McConnell AFB, KS
Title: Nurse/Mental Health Technician nicated to the incoming team. Title: Revision of the
Change of Shift Safety Checks Data collected over six months of track- Medication Renewal Process
ing the safety checks indicated that poten-
The mental health unit team at Wilford tial hazards, easily accessible to at-risk The 22nd Medical Group designed an
Hall Medical Center implemented a simple patients, did exist and. With each successive alternative process for responding to med-
but effective schedule of “safety checks” to month of safety checks, however, fewer ication renewal calls which improved both
reduce the likelihood of patient self-harm or hazards were identified. Over the initial six efficiency and the quality of follow-up care
suicide. Responding to the reality that suicide month period of data collection, there was for patients.
is the second most frequently reported sen- a seventy-five per cent (75%) reduction in Concerned that nurses were spending
tinel event nationwide, the Wilford Hall team the number of hazards found. too much duty time dealing with requests
recognized that their current safety protocols Providers in the Wilford Hall mental for medication renewal, a team was formed
could be reviewed and strengthened. health unit have created a safer environment to find a better way to field calls. Their
The team developed a structured safety for their at-risk patients. By standardizing answer was consolidation of calls to a ded-
check process designed to prevent patient the safety check process they have addressed icated renewal line, open twenty-four
self-harm or suicide by ensuring that a perceived patient need; by utilizing a team hours a day, seven days a week. Technicians
harmful objects are identified and approach they have assumed joint responsi- were specially selected and trained to
removed. The safety check is performed by bility for the safety of their patients. Continued on Back
Patient Safety Awards lizing the Clinical Microsystems frame- only 38% of children were unable to open the
Continued from Front work, with the goal of ensuring that each MDG bottles, a full 98% could not open the
retrieve the messages. A Failure Mode and patient interface is the most effective and vendor’s bottle. Based on these results, the
Effects Analysis of the new process was con- productive possible, the team reflected on Pharmacy discontinued use of their bottles
ducted prior to implementation. Relying on the people, patients, processes and patterns and switched to the vendor’s bottles,
standardization and communication, the associated with each problem. They tailored Taking responsibility for the safety of
process has proven to be a success — nurs- these specific solutions: 1) use of fetal mon- patients throughout the system, the 49th
es have been freed up for other duties, and itors has been expanded and enhanced; 2) MDG Pharmacy has shared the informa-
the technician-generated telephone con- capture of RVUs has increased 55%; 3) tion they uncovered through Air Force
sults have provided adequate information admission lab test results are available patient safety channels and as a product
for appropriate provider responses. sooner, allowing treatment to begin with- alert. Their vigilance and practical use of
A welcome unintended consequence has out delay; 4) new dedicated epidural infu- technology has served to ensure a safer
been noted since inception of the alternative sion pumps have increased patient safety environment for patients well beyond their
retrieval process — monitoring of patient and patient satisfaction; 5) elective Cesare- own population.
follow-up has improved. In developing the an sections are scheduled to align with ward
new system, physicians approved standard staffing; 6) pre-surgery lab work for elective Use of Technology
monitoring guidelines for technicians to fol- Cesarean sections is now day the day before Madigan Army Medical Center,
low as they field renewal calls. When techni- surgery, eliminating delays 7) point-of-care Tacoma, Washington
cians identify a patient who has not had testing for after-hours surgical patients has Title: Development and Implementation of a
required lab work or follow-up within the improved the lab test and results process. Mobile Obstetric Emergencies Simulator
specified time, they notify the patient of the In addition to these discrete process
need for further care and approve only a improvements, providers at Sigonella cite A recent report estimated that nearly
limited amount of medication until moni- more global rewards from their Microsys- 40% of all maternal deaths in the US
toring has been accomplished. tems experience. Working together as a could be avoided with better obstetric care
This award-winning system change, root- team to improve their care delivery process during emergencies. Directly responding
ed in the team approach to identifying and has created a new sense of shared responsi- to this need, the Andersen Simulation
implementing improvement, has impacted bility, has deepened morale, and has Center at Madigan Army Medical Center
patient safety indirectly — nurses are off the renewed their dedication to their mission of developed the Mobile Obstetrics Emer-
telephone and back to patient-centered patient-centered care. gencies Simulator.
duties — and directly — with patients receiv- Personnel train on the simulator to
ing enhanced follow-up management. Use of Technology experience those very emergencies identi-
49th Medical Group, Holloman AFB, NM fied in the literature as the cause of the
Implementation of System Title: Child Resistant Packaging majority of poor outcomes – shoulder dys-
Changes or Interventions tocia, breech vaginal delivery and postpar-
US Naval Hospital Sigonella, Scicily, Italy Technology to the rescue is an apt tum hemorrhage. The simulator includes a
Title: Clinical Microsystems description of the award-winning tech- full size birthing mannequin, a mobile cart
nique the Pharmacy at Holloman AFB showing vital signs, and a digital video sys-
By agreeing to serve as a pilot site for employed to address a startling potential tem that allows for post-emergency review.
implementation of the Clinical Microsys- patient safety problem. Told by a mother Unique in its goal to combine simulation
tems framework, under the supervision of that her two-year old was able to open a and TeamSTEPPS training, the simulator
the Center for Education and Research in medication bottle they dispensed (without integrates high fidelity simulation training
Patient Safety (CERPS), US Naval Hospital harm, in this case) the Pharmacy staff initi- and a no-fault electronic debriefing system
Sigonella embraced a multi-faceted systems ated a review of their medication bottles to to evaluate and instruct in both the techni-
change. The parturient labor and delivery ensure they comply with standards for cal aspects of patient care and TeamSTEPPS
process was chosen as the focus of Clinical child-resistant packaging. training during emergencies.
Microsystems scrutiny and application. Working with a pediatrician, the Phar- Portable and inexpensive, the Mobile
The team at Sigonella studied the labor macy designed two studies to test their med- Obstetrics Emergencies Simulator has
and delivery clinical work environment and ication bottles. In both studies, staff meas- been replicated and shared with other
identified seven problematic processes: 1) ured the time it took children to open the DoD facilities. Currently in place at eight
underutilization of maternal fetal moni- 49th Medical Group (MDG) bottles as DoD sites, including Army, Navy and Air
tors; 2) loss of relative value units (RVUs); opposed to the time needed to open a bottle Force, in addition to Madigan AMC, the
3) delayed lab tests and treatment on from an outside vendor. The studies were simulator is a technologically sophisticat-
admission; 4) same pumps used for intra- conducted at the 49th MDG Pediatric Clinic ed, comprehensive response to a critical
venous and epidural infusions; 5) schedul- and at the local Child Development Center. training need. Patient safety is well served
ing of elective Cesarean sections stressed Results from both studies demonstrated across the MHS by Madigan’s use of tech-
ward staffing; 6) delay in starting elective that the medicine bottles used at the 49th nology and teamwork to train providers to
Cesarean sections because of late lab work; MDG did not meet the standards for child respond more effectively in emergent situ-
7) inefficient process for obtaining lab test resistant packaging promulgated by the Con- ations where competence and experience
results for after-hours surgical patients. Uti- sumer Product Safety Commission. While improves outcomes.