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FALL 2005

Page 3 PSC – Safer Handoff Tips

Page 4 PSC – Retained Surgical Instruments

FALL 2005
S Page 6 Patient Safety Awards Reminder

Page 7 Patient Safety In Jeopardy?



Guidance in Meeting JCAHO 2006
Patient Safety Goals

he Joint Commission on the Accred-
itation of Healthcare Organizations
(JCAHO) reviews and enhances its
set of National Patient Safety Goals annual-
ly. First published in 2003, the goals are pri-
marily based on information derived from
the JCAHO Sentinel Event database. Their
purpose is to promote specific improve-
ments in patient safety by highlighting
problematic areas in health care, describing
evidence and expert-based solutions to
these problems, and evaluating accredited
organizations for continuous compliance
with the specific requirements associated
with each Goal.
The DoD Patient Safety Program is
committed to assisting providers as they
adapt their practices to implement the
requirements of the Patient Safety Goals.
The Toolkit and practice suggestions Sample slide from Handoff Toolkit Power Point presentation, illustrating the
information foundation for the “I PASS THE BATON” mnemonic.
described in this article have been devel-
oped specifically to provide DoD facilities
with background information and practi- HEALTHCARE COMMUNICATIONS training, and, in fact, the handoff is a famil-
cal guidance related to JCAHO Safety DURING TRANSITIONS OF CARE iar tool, utilized to improve communication
Goals 2E and 8A/B. In January 2006, and teamwork behavior. New JCAHO
accredited organizations must comply with The DoD Patient Safety Program (PSP) requirement 2E, which mandates a stan-
new implementation expectations for these has provided robust training in healthcare dardized approach to handoff communica-
goals. The Handoff Toolkit will be accessi- team coordination from its earliest days. As tions, shines a spotlight on this teamwork
ble on the DoD Patient Safety Website the PSP has matured, so has its team train- element, creating the opportunity to inte-
( on ing curriculum, now known as TEAM- grate this existing team strategy across the
December 1st, and is recommended as a STEPPS, administered by the DoD Health spectrum of healthcare practice.
helpful template for Military Treatment Care Team Coordination Program. Strate- In elevating the handoff to the level of a
Facilities as they review their individual gies for effective handoff communications National Patient Safety Goal requirement,
procedures for handoff communications. have been an integral part of TEAMSTEPPS Continued on Page 2
Patient Safety
Program Tools
Continued from Page 1
JCAHO explains that “…the primary objec-
tive of a “hand off ” is to provide accurate
information about a patient’s/client’s/resi-
dent’s care, treatment and services, current
condition and any recent or anticipated
changes. The information communicated
during a hand off must be accurate...”
JCAHO’s implementation expectations for
effective handoff communications are that
handoffs be interactive communications that
include up-to-date information, and require
a process for verification of the received
information. Interruptions during handoffs
are to be limited, and the receiver of the
handoff information should have an oppor-
tunity to review relevant patient/client/resi-
dent historical data.
The Toolkit developed by the PSP Health
Care Team Coordination Program builds on
the knowledge base underlying existing team
training and TEAMSTEPPS in particular. It Sample slide from Handoff Toolkit Power Point presentation suggesting the NEXT STEPS
for MTFs in implementing Handoff initiatives.
begins with the JCAHO requirements, but
seeks to provide a fuller understanding of the prompts providers to share information within DoD facilities. As an acknowledged
components of effective information trans- more efficiently and effectively among all lev- leader in the field of teamwork training, the
fer. Users will find a thorough review of gen- els of professional expertise, making explicit DoD Health Care Team Coordination Pro-
eral industry and specific healthcare research the communication of information that has gram, with your help, is in a unique position
in the area. Lessons learned from experience often been lost during handoffs. to make a real contribution to our patients
in emergency departments, intensive care The Toolkit concludes with a set of rec- and providers alike by integrating teamwork
units and operating rooms are noted. A con- ommendations for each facility to consider as and communication and creating a model
sistent dilemma described in all settings is the it establishes its individual handoff program. handoff process.
challenge of balancing the need for efficiency From leadership support to program design
with the need for effectiveness in handoff to preferred tools, the recommendations MEDICATION RECONCILIATION PRACTICE
communications. Passing too little informa- cover the critical elements of the optimal SUGGESTIONS
tion increases the potential for errors; requir- healthcare handoff. Rather than prescribe one
ing too much information creates a burden- standardized approach, the Toolkit provides a The Center for Education and Research in
some process that may be ignored in the press full range of information designed to explain Patient Safety (CERPS) at USUHS has assist-
of day-to-day practice. and facilitate well-structured handoffs, which ed in developing a compendium of informa-
One goal of the Toolkit is to assist can be adapted to the diverse cultures of the tion, research and practice guidelines to assist
providers find a balanced process for hand- DoD medical community. Included in the MTFs develop a systematic process for recon-
offs across the continuum of care. To that Toolkit for use by facilities are an extensive ciling medications. This effort is a direct
end, five current strategies are discussed: the bibliography and list of relevant resources, response to JCAHO National Patient Safety
I-SBAR, Expanded I-SBAR, FIVE-Ps, Data helpful illustrations, Frequently Asked Ques- Goal 8, which requires that health care organ-
TRIANGLE and the I PASS THE BATON tions related to handoffs and TEAMSTEPPS, izations “accurately and completely reconcile
mnemonic. Each option is analyzed in the and a supporting Power Point presentation. medications across the continuum of care”,
context of human factors knowledge, medical Dr. John S. Webster, a member of the effective January 1, 2006. It builds on the
errors commonly seen during healthcare DoD Health Care Team Coordination Pro- proactive initiative introduced at the National
transitions, the complexities of the healthcare gram, believes this coordinated effort to Naval Medical Center (NNMC) Bethesda,
process, JCAHO mandates and the need to structure handoff communications provides where staff developed a workable, repeatable
balance effectiveness with efficiency. The I an opportunity for significant improvement management response to medication recon-
PASS THE BATON mnemonic, which stands in patient safety. Each Service will oversee ciliation using the existing capabilities of the
for Introduction, Patient, Assessment, Situa- implementation of the handoff initiatives Composite Health Care System (CHCS).
tion, Safety Concerns, Background, Actions, within its facilities. Feedback from healthcare In establishing medication reconciliation
Timing, Ownership and Next Steps, is recom- providers will be solicited and incorporated as a safety goal, JCAHO recognizes evidence
mended as the most intuitive, flexible strate- into the Toolkit, which will be reviewed and from numerous studies which documents a
gy in current use. I PASS THE BATON adjusted to reflect emerging best practices Continued on Page 8


Feedback and Suggestions Based on Your Reporting
record, it has been misinterpreted, or the the record and all appropriate information
Practicing Safe receiver is not in a position to effectively (lab, radiographic, other diagnostic results)
Handoffs hear and retain it. for the consultant at the time of the exam.
As MTFs work to meet the JCAHO  Consult physician signs and date-
Suggestions to Improve Problem Areas expectations, aided by the DoD Toolkit out- stamps the chart to indicate concurrence,
Mary Ann Davis, RN, BSN, MSA lined on page 1, the PSC offers these addi- and initials the diagnostic result to indicate
Nurse Risk Manager, Patient Safety Center tional practical suggestions to assist in that a review was performed.
improving the effectiveness of handoff com-  Impromptu or “sidewalk” consulta-

ecognizing the importance of the new munications. tions can be particularly problematic. Have
JCAHO 2006 Patient Safety Goal # 2E, the patient record and any diagnostic exams
which requires the implementation of Clinical test orders and results present during all consults, rather than rely-
a standardized approach to handoff commu- Commonly part of the information ing on a verbal description. Consult physi-
nication, the DoD Patient Safety Center has handed off, orders and/or results may not be cian should initial diagnostic reports and
reviewed relevant literature and information known or documented at the time of the write a brief initial note, followed by a longer
received from our Military Treatment Cen- handoff. Consider these improvements: report.
ters (MTFs). While the definition of a hand-  Include a laboratory flow sheet in the  Provider-provider communication
off — the transfer of information between medical record to document the tests should explicitly establish who has primary
health care providers — seems easy to ordered, with order dates, test results, and responsibility and agree on a clear line of
understand, experience shows that achieving dates results are received. responsibility for follow-up to prevent mis-
an effective and efficient transfer continues  Have technicians review the laborato- understanding.3
to challenge busy caregivers. ry flow sheet when preparing the record for
As you exchange information about your a patient’s appointment; print any labs/test Documentation
patients, keep in mind that the primary results that are not recorded; give test results Documentation should be reviewed
objective of a handoff is to provide accurate to the provider to review and record during prior to, or at time of, handoff:
information about a patient’s /client’s /resi- the patient’s appointment.  Medical staff should clarify critical
dent’s care, treatment, services, current con-  Have providers review the lab flow information (e.g. patient situation, safety
dition and any recent or anticipated change. sheet at each visit and retrieve, record or concerns, background, planned actions and
JCAHO’s implementation expectations order outstanding labs/test results. their timing, and those responsible for
require up to date information, interactive  Document verification of verbal com- patient care) in the medical record or the
communication, limited interruptions dur- munication of laboratory results in the med- appropriate transfer document. “I PASS THE
ing handoffs, a process for verification of the ical record at the time the information is BATON”, a mnemonic recommended in the
received information and the opportunity by communicated. Toolkit, will assist this process.
the receiver of the handoff information to  Have health care providers identify a  Log books or spreadsheets should be
review patient /client/resident historical surrogate to review test results in their managed by centralized personnel within a
data.1 absence. clinic or ward to track tests and their results. 4
In DoD practice, as is true across the  Hand-carry reports of incomplete and  Utilize a white board or computer for
larger healthcare system, handoffs are com- abnormal tests to the provider or surrogate; the most recent vital sign and test results
mon in the emergency room and clinic set- enter results of incomplete or abnormal tests during shift reports. Update all patient infor-
ting when multiple providers treat the into a database and review each month. Ver- mation prior to the report and highlight any
patient, during change of shift or personnel ify provider contact with the patient con- areas of concern that should be addressed.
and when a specialist or consultant is need- cerning abnormal results.
ed. Providers rarely have complete medical  Involve patients in their care. Ensure 1
Joint Commission 2006 National Patient
record information when the patient that they understand what tests are ordered Safety Goals Implementation Expectations,
receives care in multiple settings. Often, and when they should receive results, thus accessed 9/22/05,
patients are sent to facilities where the pre- adding additional checkpoints to the test fol- credited+organizations/patient+safety/06_nps
vious medical records are not available. In low-up process.3 g_ie.pdf
the acute care setting the exchange of infor- Shepard, A; Kostopoulou, O. Fragmenta-
mation frequently occurs at change of shift Consultations between providers tion in Care and Potential for Human Error,
or change of coverage, commonly with The exchange of information among accessed 9/22/05,
reports which are mostly verbal, and may be consulting providers can be either verbal or johnson/papers/HECS_99/Sheppard_Kostopou
ambiguous. Some handovers are done from written, but special care must be taken to lou.htm
memory with no documentation.2 Impor- ensure that it is complete, accurate and up to 4
Gandhi, T. K. Commentary: Fumbled
tant information often is not conveyed date. These actions will improve this process: Handoff: One Dropped Ball after Another, ANN
because it has not been included in the  Provider requesting a consult provides Intern Med. 2005; 142:352-358


tive x-rays were used to detect radiopaque eign bodies. There are reports that some
The Final Count sponges, the radiograph was falsely negative. medical facilities have abandoned this prac-
Retained Surgical Foreign Bodies The authors note that the literature tice.11 Use of this simple, preventive, and
describing the incidence of iatrogenic foreign widely accepted measure is not universal.
Pamela Copeland, RN, BSN, JD, ARM bodies is highly limited in quantity and qual- "Legislation does not prescribe how counts
Nurse Risk Manager, Patient Safety Center ity. Additionally, the existing system of should be performed, who should perform
them, or that they need to be performed.12

ailure to remove surgical instruments at sponge and instrument counts probably
the end of a surgical procedure may be works well, but there is no evidence to The law only requires that foreign bodies not
a more common occurrence than sus- describe the actual failure rate. What little be negligently left in patients.”13 The Associ-
pected. A recent study reports that this may evidence exists suggests that system failures ation of Operating Room Nurses (AORN)
occur in as many as 1 out of every 100 cases are the result of human related factors (i.e., has published accounting guidelines for
to as few as 1 out of every 5000 surgical cases, the count is not performed, or is ignored), instruments used during surgical proce-
with associated mortality ranging from 11 to and that ancillary methods such as x-rays are dures. The following practices were devel-
35%.1 also fallible. The authors conclude that the oped by the AORN Recommended Practices
The process by which counts are per- industry is left with a paucity of data regard- Committee and became effective January 1,
formed is not standardized. Individual hospi- ing the prevalence of this error and the effec- 2000.
tal policies vary widely, relative to their surgi- tiveness of preventative measures.6 “Sponges should be counted on all proce-
cal sponge/sharps/instrument counting pro- A recent study by Gawande, et al, consid- dures in which the possibility exists that a
cedures. The Joint Commission on the ered the risk factors for retained instruments sponge can be retained. Sponge counts
Accreditation of Hospitals (JCAHO) does and sponges after surgery.7 They conclude should be taken:
not dictate that counts must be conducted that “studies of error to date have generally 1. Before the procedure to establish a base-
nor does it prescribe how counts should be measured only the frequency of the outcomes line.
conducted in the facilities that perform them. of specific types of errors, not the roles of 2. Before closure of a cavity.
Historically, the JCAHO sentinel event policy particular contributing factors.”8 Their 3. Before wound closure begins.
has specifically stated that “unintentionally research team used a retrospective case-con- 4. At skin closure or end of the procedure.
retained foreign body without major perma- trol design involving the records of medical 5. At the time of permanent relief of either
nent loss of function” does not require malpractice claims and incidence reports. the scrub person or the circulatory
reporting.2 In June 2005, JCAHO revised the Additionally, members of operative teams nurse.”14
list of reviewable sentinel events to include were interviewed. In this study, 54 cases The purpose of these prudent patient
the unintended retention of a foreign object involving 61 events were reviewed (69% safety measures is to ensure that discrepan-
in an individual after surgery or other proce- sponges and 31% instruments).9 cies at any stage of the surgery will require the
dure.3 According to Gawande, et al, cases involv- team to do a repeat count. If the discrepancy
According to Gibbs et al., the prevalence ing the retention of a foreign body after sur- persists, then appropriate steps will be taken
and severity of this target problem is gery significantly increased in emergencies, to locate any unaccounted items.
unknown, and without accurate information, unplanned changes in procedures, and with Retained sponges and instruments con-
the true magnitude of the opportunity for individuals having a higher body-mass tinue to be a disturbingly repetitive problem.
impact is unclear.4 index.10 The group’s findings support the Verna Gibbs, MD, of the University of Cali-
The Kaiser, et al, study reviewed 67 med- confirmation that leaving behind foreign fornia at San Francisco notes a continuing
ical malpractice claims involving retained bodies in a patient after surgery is an uncom- mantra that “current preventative practices
foreign bodies.5 The study notes: mon but dangerous error. They note the fol- fail due to human related factors. Surgeons
1. 55% of retained sponges were found lowing sequelae: use nonradiographically detectable sponges,
after abdominal surgery, 16% after vaginal  In one case, the retained object result- counts are not performed, and when they are
surgery. Falsely correct sponge counts can be ed in death. performed and errors occur, backup detec-
attributed to:  In 22% of the cases, the retained for- tion systems are not systematically
 Team fatigue eign bodies resulted in small-bowel fistulae, employed.”15
 Difficult operations obstruction, or visceral perforations. JCAHO now requires this event to be
 Sponges “sticking together”  69% of the patients required re-opera- reported regardless of the patient outcome.
 Poor counting system tion for removal of the object and manage- Collection of this data will assist the industry
2. In cases involving retained sponges, the ment of the complication. accurately quantify the prevalence of this
sponge count had been falsely reported in  The foreign body in the remaining event type. Through qualitative analysis of
76% of non-vaginal surgeries; in 10% of the patients the data and methodical human factor
cases no sponge count had been conducted. - was expelled, assessment, guidelines and tools can be
Incorrect sponge counts that were accepted - could be removed at the bedside, developed for surgical teams and their facili-
prior to closure resulted from: - was discovered incidentally and ties to implement. This process change will
 Surgeon dismissing an incorrect count removed at the time of another operation. enable the team to no longer ask the question
without re-exploring the wound. The majority of surgeons and nurses typ- “was the count correct” but to ask and accu-
 Nursing staff allowing an incorrect ically rely on the practice of counting the rately determine “is there a sponge or instru-
count to be accepted. sponges, sharps, and instruments as a means ment in the patient?” before finally closing
 In 3 of 29 cases in which inter-opera- of eliminating the possibility of retained for- the surgical site.


Laurwers PR, n Hee RH. Intraperitoneal Ann Surg 1996;224:79-84. 2000 standards, recommended practices and
gossypibromas: the need to count sponges. Ibid p 80. guidelines: with official AORN statements. 1st
World J Surg 2000;521-527. Gawande A, Studdert D, Orav EJ, Brennan ed. Denver, Colorado: Association of operating
Wig JD, Goenka MK, Suri S, Sudhaker PJ, TA, Zinner MJ. Risk factors for retained instru- room nurses; 2000:213-219.
Vaiphei K. Retained surgical sponge: an unusu- ments and sponges after surgery. N Engl J Med. Ibid p. 213.
al of intestinal obstruction. J Clin Gastroenterol 2003;348:229-35. Ibid p. 215.
8 15
1997;24:57-58. Ibid p. 230. Gibbs VC. Case & Commentary. Did we
3 9
Sentinel Event - Ibid p. 229. forget something? AHRQ Web M&M: Case
credited+organizations/sentinel+event/se_inde Ibid p. 232. Commentary.
x.htm Accessed October 17, 2005. AORN Online Journal; November 2000: case.aspx?caseID=27 Accessed October 9, 2005.
4 16
Gibbs VC, VaAuerbach AD. Chapter 22. Clinical Issues Gawande A, Studdert D, Orav EJ, Bren-
The retained surgical sponge nal/2000/nov2kci.htm. Accessed October 16, nan TA, Zinner MJ. Risk factors for retained
clinic/ptsafety/chap22.htm - 10k. Accessed 2005. instruments and sponges after surgery. N Engl J
October 17, 2005. Reno D, Lobb J. Recommended practices Med. 2003;348:234.
5 17
Kaiser CW, Friedman S, Spurling KP, Slow- for sponge, sharp, and instrument counts. VA National Center for Patient Safety:
ick T, Kaiser HA. The retained surgical sponge. AORN Recommended Practices Committee. In:

Risk Reduction Strategies for Retained Foreign Bodies*

Surgeons Hospital Staff (Nurses and Surgical Assistants) Radiologists
Confirm counts when passing off needles and sponges. Count all items, even prepackaged items. Ask for additional information if you need it:
• what item,
• what quantity; and
• likely location.

Never cut sponges. Each sponge used should have an x-ray Count at start of procedure, after each cavity is closed, at Get repeat films and over penetrated films as needed. (This
detectable strip. skin closure, and following any change in staff. may help in identification of items located behind dense

Do not prop up internal organs with surgical towels. Make sure any x-rays ordered are documented and co- Call all “significant” findings directly to the attending sur-
signed, films are sent promptly for a STAT interpretation geon.
by the radiologist, and that the indication for why the film
is being done (such as to rule out a retained sponge or
needle) is made known to the radiologist.

Ensure counts are done on all items. Check kick-buckets and trash cans before initiating Requests for stat X-rays in the OR for surgical cases with an
sponge and instrument counts.17 incorrect count should include:
• Type of procedure;
• Surgical site;
• Surgeon, and
• Nature of missing item.
Stat intra-operative X-rays should be jointly or sequentially
reviewed and discussed by the surgeon and the radiologist.17

Inform circulating nurse when you pack a wound, with what item, Enforce quiet or dedicated time during the final counts so Recognition of retained bodies after surgical procedures
and how many items are used. nurses performing them are not disturbed.17 should be an integral part of residency training in radiology.17

Request count with any change of staff. Conduct observational study of count process to learn Ensure that portable X-ray machines can provide adequate
vulnerabilities, identify specific distractions, and improve imaging data to meet the needs for assisting with identifica-
process design.17 tion of retained items.17

Ensure count is done at start of case, after leaving each cavity, Maintain continuity whenever possible by having the
and upon skin closure. Remember you may need to tell the nurse same team or OR staff start and complete a case. When-
you need to do a count (he/she may not know, for example, that ever possible, lengthen assignments for consistency.17
you are leaving a cavity).

If the post-procedure count is off, then: Annually, assess staff competencies on the management
• Make a visual inspection of the operative area. of sharps instruments, and sponges.17
• Do a manual search of the operative area.
• Obtain x-ray and have it read STAT by the radiologist.
• Make sure the x-ray taken includes all the operative fields in
• Document all measures taken.
The practitioner who orders the x-ray must follow up and read
both the body and conclusion of the official radiology report. This
is in addition to any verbal reports taken over the phone or in per-

Consider routine intraoperative radiographic screening in select-

ed, high-risk categories of surgical procedures (obese patients,
closed-to-open procedures, emergent cases, and unexpected *Text in the table above (unless otherwise noted with reference num-
change in surgical procedures).16 bers) has been used with permission from the University of Florida
All surgeons should be educated and trained in the appropriate Self-Insurance Program/Risk Management and Loss Program.
and standardized sponge and instrument count procedures.17
All surgeons should know and adhere to the institution’s policies
and practices for sponge and instrument counting.17


Interesting Resources To Explore
Health Affairs – Web Exclusive the Robert Wood Johnson Foundation and “The National Medical Error Disclosure and directed by IHI to define and spread best Compensation (MEDIC) Act”
“The Complex World of Military Medicine: practices in patient self-management sup- S.1784, 109th Cong., 1st Sess. (2005)
A Conversation with William Winken- port. Bill introduced to Senate by Senators Clinton
werder” (D-NY) and Obama (D-IL) in Sept, 2005 to
Dr. Winkenwerder, Assistant Secretary of National Quality Forum establish a program requiring hospitals to
Defense for Health Affairs, engages in a wide- disclose errors to patients and offer financial
ranging discussion of the military health- “Improving Patient Safety Through settlements where appropriate; create a
care system. He discusses strategies for pro- Informed Consent for Patients With Limit- national patient safety database; and protect
viding care on the battlefield and at home, ed Health Literacy” statements about and apologies for errors
and comments on clinical quality efforts. Wu HW, Nishimi RY, Page-Lopez CM, Kizer, from use in malpractice actions. Full text of
KW legislation can be accessed from this link.
Ready, Set, Patient Safety Go to “Project Summaries” on website for report on the experiences of four hospitals American Medical News
Book referenced in ”Patient Safety In that successfully implemented NQF Safe
Action” feature of this Newsletter containing Practice 10 – which calls for improved com- “Patient Safety Gets Boost From Law Easing
suggestion for patient safety Jeopardy game. munication in the informed consent process Fear Of Reporting”
A wide variety of entertaining training – focused particularly on patients with lim- August 15, 1005;Vol 48, No 21: 1-2
methods are included in the text. $129.00 ited health literacy. The report contains key Description of the federal Patient Safety and
lessons learned and recommendations to Quality Improvement Act of 2005, signed
Patient-Centered Resources assist providers in implementing SP 10. into law in August. Statute directs DHHS to
Agency for Healthcare Research certify Patient Safety Organizations and a Disclosure and Error Reporting system through which healthcare providers
Guide to Health Care Quality: How To Know Archives of Internal Medicine can confidentially report errors. Reports will
It When You See It stay confidential and cannot be used in
Booklet released by the Agency for Health- “Disclosing Harmful Medical Errors to criminal, civil or administrative actions. See
care Research and Quality in September as Patients”
part of its consumer education campaign to Gallagher, TH, Levinson W., 2005;165:1819- bin/bdquery/z?d109:s.00544 for statute.
help people take a more active role in their 1824
own health care. Guidance on talking to Commentary provides an overview and per- Center for Urban Policy and the Environ-
doctors, understanding health care quality spective on the challenging issue of disclo- ment, Indiana University Pudue University
and finding quality information. Online at sure of medical errors; advocates a proactive
the above address; order free single copies at approach, including developing guidelines “Medical Error Reporting System Could
301-427-1244. for disclosure and incorporating these prac- Boost Patient Safety”
tices into existing quality improvement ini- Ebright PR, Rapala K., September 2005:1-7
Institute for Healthcare Improvement tiatives. Includes a lengthy bibliography on Issue brief outlines the importance of devel- error disclosure. oping a state medical errors reporting sys-
“Quality Allies: Improving Care by Engaging tem in Indiana; factors that should be con-
Patients” Patient Safety Network sidered; and general characteristics of a good
An ambitious national program funded by state reporting system.

Patient Safety in December 2005.

Established to recognize leadership
the Military Healthcare System.
Detailed information on project guide-
Awards and innovation in quality, safety and com-
mitment to patient care, the Patient Safety
lines and evaluation criteria is posted on
the homepage of the DoD Patient Safety
Submissions Deadline: Nov. 30 th, 2005 Awards are presented in the categories of Website:
Technology, Policy/Procedure and Team The Patient Safety Award Submission

he third annual DoD Patient Safety Training. To be eligible for an award, a Package, containing a project timeline and
Awards will be presented at the project or initiative must demonstrate templates for use, can be downloaded from
2006 TRICARE Conference in Jan- that it has been tested and proven to the site. A review of the projects awarded
uary. MTFs are encouraged to submit reduce errors, improve patient safety and recognition in the past can be found in the
projects for consideration by November outcomes. Projects must be data driven, 2004 and 2005 Winter Newsletters, which
30, 2005. Award recipients will be notified practical, creative and transferable across are archived and accessible on the website.


Experiences and Suggestions From the Field

51st MDG Patient

Safety Jeopardy
What is a Great Patient Safety
Teaching Tool?

o say patient safety at the 51st MDG,

T Osan Air Base, Korea is all fun and

games might be something of an
overstatement, but in fact, their own version
of Jeopardy has staff thoroughly enjoying a
challenging review of patient safety basics.
Developed by Patient Safety Manager Karen
Sutton, this interactive computerized ver-
sion of the familiar television game show
has proven an especially creative and popu-
lar approach to patient safety training.
The idea for the Jeopardy game came
from Ready, Set, Patient Safety, a training
book available from HCPRO, (see Links sec-
tion of this newsletter, page 6, for more
information). Ms. Sutton adapted the paper
version of the Jeopardy game suggested by Samples of
the book. She added a medical team training the Patient Safety
Jeopardy game.
category, and turned the exercise into an
interactive, entertaining experience com-
plete with sound and music. Not surprising-
ly, she chose the theme song from MASH as
the sign-off tune!
The game is easy to play. Staff simply
open up the Power Point slide show and click
“view show”. On slide two, they pick a cate-
gory, and click once for text and accompany- safety monitors for use in their respective and teams from hospital departments will
ing Jeopardy music. The next click will elicit areas via email; a separate link was sent out compete for prizes and the singular honor of
a buzzer sound and the Jeopardy answer, in to all hospital personnel summarizing the being named Jeopardy Patient Safety Grand
the form of a question, of course! The arrow game and identifying the file location for Champion.
key navigates staff through the game’s cate- access. Additionally, Ms. Sutton incorporat- At the 51st MDG, the focus on patient
gories, while a click on “exit” leads directly to ed the Power Point presentation into the safety training is serious, but the way in
the final slide and the farewell music. Newcomers Orientation, which all new which it is accomplished makes room for
Ms. Sutton, an experienced patient safe- employees are required to attend within simple, interesting and fun exercises. In Ms.
ty manager assigned to Osan AB since thirty days of their arrival. Sutton’s experience, this is the best way for
November, 2003 (now at Lakenheath AFB, Staff reaction has been enthusiastic. information to be remembered and
England) credits senior leadership support Rather than “just another power point brief- reviewed regularly. We are pleased to share
as a major key to the success of the Jeopardy ing”, they have reported “pleasant surprise” this patient safety Jeopardy game from the
game. She previewed the game to senior at the fun they’ve had with the quiz-show 51st Medical Group of “Combat…Medics”
leadership at an Executive Committee meet- format. To date there has been no formal located at the “Tip of the Spear”.
ing. With their blessing, the game has been competition within the hospital, but plans You can play the 51st MDG Jeopardy
widely distributed throughout the hospital. are afoot to hold a Jeopardy tournament as game by accessing the DoD Patient Safety
It was featured in the bi-monthly medical part of National Patient Safety Week activi- Website and following the appropriate links.
group newsletter; electronic copies were dis- ties this coming spring. A Final Jeopardy For specific information, contact Karen Sut-
tributed to hospital leaders and to patient question will be added to the presentation ton at


Patient Safety review with the patient/family to create an
Program Tools
Continued from Page 2
accurate and full-range list of medications
upon admission.
significant error rate in the medication use
history obtained by physicians in both ambu-
latory and in-patient settings. Over half of all
All in-patient medication orders are
recorded in CHCS, thus augmenting a
patient’s profile. This information is avail-
able at the time of any inter-hospital
Patient Safety is published by the Department of
medication errors occur at transitions of unit/care transfer. At discharge, a final med- Defense (DoD) Patient Safety Center, located at the
care, when medication orders are written ication list can be generated and compared Armed Forces Institute of Pathology (AFIP). This
quarterly bulletin provides periodic updates on the
during admissions, discharges and transfers with the admission profile to ensure that the progress of the DoD Patient Safety Program.
within the health care system. Thus develop- patient understands any changes in medica-
ment, reconciliation and communication of tions, and that there are no prescription DoD Patient Safety Program
an accurate medication list throughout the duplications or medication omissions. The Office of the Assistant Secretary
continuum of care are essential for the reduc- patient should be provided with this final of Defense (Health Affairs)
tion of transition-related adverse drug events. medication profile to include in his/her TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike
To achieve this goal, JCAHO has imposed medical record and bring to ambulatory vis- Falls Church, Virginia 22041
two requirements: first, implementation of a its. The expectation of JCAHO requirement 703-681-0064
process, with patient involvement, for obtain- 8B, that the complete list of medications be Please forward comments and suggestions
ing and documenting a complete list of cur- communicated to the next provider, can to the editor at:
DoD Patient Safety Center
rent medications upon admission; second, more easily be met using CHCS data. Armed Forces Institute of Pathology
communication of a complete list of patient’s The medication reconciliation process 1335 East West Highway, Suite 6-100
Silver Spring, Maryland 20910
medication to the next provider. has been demonstrated to be a powerful Phone: 301-295-7242
As CERPS explains in its Introduction for method for reducing medication errors. In Toll free: 1-800-863-3263
Health Care Providers, (to be posted on the addition, medication reconciliation has been DSN: 295-7242 • Fax: 301-295-7217
Patient Safety website) medication reconcili- shown to improve work efficiency, saving Website:
ation is a systematic process designed to time at admissions, transfers and discharge. E-Mail to editor:
improve communication during transitions In the MHS, using CHCS to manage medica- DIVISION DIRECTOR,
of care by creating a current, accurate, single tion reconciliation will allow providers to PATIENT SAFETY PROGRAM:
LTC Steve Grimes
source medication profile for use by all health continue or discontinue medications already
care providers dealing with a specific patient in the system without re-writing orders at all Geoffrey Rake, M.D.
at the time any form of care is provided. Rec- points during the in-patient period. Only SERVICE REPRESENTATIVES:
onciliation consists of three basic steps: new medication orders will need to be writ- ARMY:
Major Robert Durkee
ten. The resulting reduction in writing and NAVY:
1. Collect and verify a current accurate med- transcription will not only save time, it will Ms. Carmen Birk
ication profile, including name, dosage, significantly reduce the opportunity for Lt Col Kathryn Robinson
frequency, route, and, if possible, time of medication order error. PATIENT SAFETY BULLETIN EDITOR:
last dose Adopting a formalized medication rec- Phyllis M. Oetgen, JD, MSW
2. Use profile as basis when writing med- onciliation process at each MTF, while neces-
ication orders sary to comply with the new JCAHO man-
3. Reconcile by comparing patient’s current dates, will bring DoD facilities closer to insti- DoD PATIENT SAFETY WEBSITE
profile against medication orders written tutionalizing and realizing the “five rights” of The DoD Patient Safety Website is accessible
at admission, transfer and/or discharge at: This
safe medication use: the right patient will source of the most current information
receive the right medication, at the right about the Patient Safety Program and its
The DoD Military Health System (MHS) doses, at the right time, by the right route. components is frequently updated, and
has the unique advantage of a common Additional information, supporting instruc- should be checked regularly. Features
source of medication information in the tions and training materials will be available include messages from the Director of the
Patient Safety Program, which review
Composite Health Care System (CHCS). to all MHS facilities on the Patient Safety accomplishments and announce new initia-
NNMC Bethesda has provided a template for website in early December. Information tives. The calendar of events lists all levels of
utilizing the CHCS system in implementing compiled by Navy Medicine is currently patient safety training offered by CERPS and
the medication reconciliation process. CHCS posted on the RITPO website: provides a link for registration. Patient Safe-
captures all out-patient prescriptions pro- ty marketing and educational materials to
increase patient safety awareness among
vided through DoD pharmacies. As MTFs Particular recognition for this medica- patients and providers can be ordered from
begin to develop and formalize their respec- tion reconciliation solution should go to Ms the website. The Patient Safety Program
tive reconciliation processes, access to exist- Roberta Williams, Ms Suzie Farley, NNMC Tools are posted and can be downloaded
ing CHCS profiles is a logical first step. At the Bethesda, Dr. Eric Marks, USUHS, CDR Jef- and adapted for individual MTF use. All
time of admission, information from CHCS frey Blice, Chair of the NNMC Pharmacy DoD patient safety providers are encour-
aged to make frequent access to the Patient
can be obtained, providing a base-line list of and Theraputics Committee and CAPT Safety Website a routine part of their prac-
medications for any given patient. This list David McCarthy, BUMED and the BUMED tice protocol.
can form the basis of JCAHO’s mandated 8A Risk Management staff.