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Patient FALL
Page 3 Safety Goal Actions

Page 4 Timely Links
Page 5 Project News Share
Page 6 JCAHO Campaign

A quarterly newsletter to assist DoD hospitals with improving patient safety

NATIONAL AWARD provides comprehensive patient safety DOD PATIENT
The award winning training program The submission deadline for the 2005
ARMY MAJOR was conceived by MAJ(P) Jaghab in Patient Safety Award is November 17,
2003 when he was serving as Dietetic 2004. Application documentation is
Distance Learning Program Internship Director at Brooke Army available on the DoD Patient Safety
Recognized Medical Center. A registered dietitian,
MAJ(P) Jaghab had previously devel- 2004 Award winners were highlighted
oped an MPEG series to promote the in the winter 2004 Patient Safety
A rmy MAJ(P) Danny Jaghab
received the prestigious 2004
John M. Eisenberg Award for
Army’s five-a-day program for fruits
and vegetables. Recalling this experi-
Newsletter, which can be accessed on
the website.
ence as Brooke prepared for an antici- Recipients of the Award will be noti-
Innovation in Patient Safety and fied on December 15, 2004. The
Quality on October 6th at the National pated Joint Commission on
Award will be presented at the 2005
Quality Forum Annual Meeting in Accreditation of Healthcare TRICARE Conference in January.
Washington, D.C. MAJ(P) Jaghab was Organizations (JCAHO) survey, MAJ(P)
honored for his MPEG Training Jaghab proposed the same format as DoD 2005
Program, a distance learning course an effective and efficient way to pro-
consisting of thirty-four scripts based vide hospital-wide training on the PATIENT SAFETY
on Joint Commission patient safety JCAHO patient safety goals. CULTURE SURVEY
goals and recommendations which The Department of Defense 2005
Creating the program was a Patient Safety Culture Survey is sched-
labor-intensive project. For uled for deployment within Army,
each patient safety goal and Navy, and Air Force military treatment
recommendation, MAJ(P) facilities (MTFs) in early 2005. The
Jaghab developed three two- web-based survey, sponsored and
funded by TRICARE Management
to-four minute scripts, Activity (TMA), will assess staff opin-
describing a sentinel event, ions about issues related to patient
outlining risk reduction safety in MTFs. Survey feedback
strategies, and reviewing rel- results will be provided to facilities
evant local and Medcom and can be used to raise staff aware-
ness about patient safety, to identify
policies respectively. MAJ(P) areas for improvement, and to meet
Jaghab narrated the scripts requirements of the Joint Commission
on video, edited the tapes on Accreditation of Healthcare
and converted them into Organizations (JCAHO).
MAJ(P) Danny Jaghab receiving the 2004 John M. Motion Picture Expert The kick-off for the survey will be
Eisenberg Award from Kenneth W. Kizer, MD, Group (MPEG) format. He held at the annual TRICARE confer-
asked key hospital leaders to ence January 24-27, 2005. Further
MPH, President and CEO, National Quality
Continued on page 2 details about the survey will be forth-
Forum. Photo by: COL Paul Little, US Army coming.
whose open membership
NATIONAL AWARD represents broad participa-
PRESENTED TO tion from all parts of the
healthcare system. In 2002
ARMY MAJOR the National Quality Forum
Distance Learning Program and the Joint Commission on
Accreditation of Healthcare
Recognized Organizations launched the
continued from page 1 John M. Eisenberg Patient
Safety and Quality Awards.
lend their support to the project by The awards honor the memo-
providing endorsements for each seg- ry of Dr. Eisenberg, a highly
ment. The MPEGS were then posted respected national leader in
to the hospital intranet. Over three healthcare quality, and
thousand hospital staff received emails Director of the Agency for MAJ(P) Danny Jaghab with his family: wife
on a regular basis to guide them Healthcare Research and Delmy, son, Danny and daughter, Jasmine at the
through the entire MPEG series. Each Quality (AHRQ) from 1997 John M. Eisenberg Awards ceremony in
email contained a photograph of a key until his untimely death in Washington, D.C.
leader, his or her scripted endorse- March, 2002.
ment, and a link to a designated MPEG
learning module. Staff members who Quality on the local level for a series
This year, in addition to MAJ(P) Jaghab,
watched all thirty-two MPEGS were of creative teaching/learning packets
Eisenberg Award recipients included
provided with a certificate of patient entitled “Keeping Each Patient Safe”.
Lucian L. Leape, MD, for his individual
safety training. Immediate positive achievement as a leader of the patient
feedback for the program was provid- All award recipients attended the
safety movement; and Peter J.
ed by the JCAHO surveyor in National Quality Forum meeting in
Pronovost, MD, PhD, for his research
December, 2003 when he commended October, and were introduced at a spe-
on staffing in intensive care units and
MAJ(P) Jaghab’s effort as an example cial presentation ceremony, followed
improved patient outcomes. Also
of best practices in patient safety by a reception in their honor. MAJ(P)
receiving an award in the category of
training. Jaghab was accompanied by his wife,
Innovation in Patient Safety and
Delmy, and his children, Jasmine (9)
Quality on the national level were
Recognition of the MPEG program by and Danny (7). Also attending the cer-
Kaveh Shojania, MD and Robert
the National Quality Forum gives emony in support of MAJ(P) Jaghab
Wachter, MD, developers of WebM&M,
MAJ(P) Jaghab’s initiative a national was CAPT Deborah McKay, Director of
the first internet-based patient safety
identity, and places it in the company the Patient Safety Program and COL
resource and journal. The University
of leading patient safety advocates. Eugene Miller from the Office of the
of Pittsburgh Medical Center-
The National Quality Forum (NQF) is a Surgeon General. Representing the US
McKeesport was recognized for
private, not-for-profit organization Army Center for Health Promotion and
Innovation in Patient Safety and
Preventive Medicine, where MAJ(P)
Jaghab is currently Nutrition Staff
Officer, were COL Joann
Hollandsworth, Director of Health
Promotion and Wellness, and LTC
Teresa Hall, Health Systems
Coordinator of the Directorate of
Health Promotion and Wellness.

Congratulations to MAJ(P) Jaghab from

the entire DoD Patient Safety Program
for his significant contribution to
improving patient safety and for his
nationally recognized award. All
providers are encouraged to review
the MPEG Training Program on the
DoD Patient Safety Website at:
Recipients of the 2004 John M. Eisenberg Awards, with Dennis S. O’Leary,
MD, JACHO, Mrs. Eisenberg, and Kenneth Kizer, MD, National Quality
Forum. Photo by: COL Paul Little, US Army CHPPM.
• Are there problems with the
NEWS FROM THE blood or tissue; alphabetic order or in order
of like-sounding medica-
• Affix “name alert “ stickers
equipment that should be tion);
reported to the manufactur-
• Should the equipment be
er; to the areas where look alike
Feedback and Suggestions or sound alike medications

• When critical laboratory values • Place additional label on

changed or modified? are stored;
Based on Your Reporting
are missed in the computer sys- newer medications to differ-
tem check the information that entiate them from estab-
• Is there a way to highlight • Review the physical layout
is provided within the system: lished medications;
GOAL abnormal levels for easy of medication bins; can addi-

• Are abnormal levels listed in

STRATEGIES viewing; tional space be allocated to
help with the handling and
• When different drug formula-
a conveniently accessible storage of the medications?
area within the computer
Suggestions for New 2005
• Should additional blood tests
system; tions (e.g.,Amphotericin B) have
increased the likelihood of the
• Consider limiting the med-
be given critical value levels wrong drug being given:

• When the provider isn’t notified

in the system?
By: Mary Ann Davis, RN, BSN, MSA
ication to one or two formu-
Nurse Risk Manager, Patient Safety
• Change the labels so they
Center of the abnormal blood results lations;
look at how the information was

• Is there a list of laboratory

transmitted: are written with the brand
I mplementation of the JCAHO 2005
National Patient Safety Goals is
quickly approaching.The National tests that are routinely • Order by brand and generic

• Are the results reported via • Encourage staff to use both

Patient Safety Goals were developed to reported; name;
promote specific improvements in
• Place an alert in the comput-
patient safety.They continue to multi- email, phone or with a the brand and generic name;

• Who sends and receives the

ply and/or become accreditation stan- paper report;
dards, as safety becomes an integral er indicating the need to use

• How and when is the infor-

part of patient care.The 2005 Patient results; the brand name with the
Safety Goals include five new goals generic name when pre-

• When there is a computer error

and three new requirements.The DoD mation given to the ordering scribing the medication.

• When there is a repeat collec-

Patient Safety Center has reviewed provider?
information received from our Military related to a look-alike, sound-

• Mandate the complete name

Treatment Centers (MTFs), JCAHO and tion of a hemolyzed specimen alike medication:
relevant literature to supply sugges- from the same patient clarify the

• Install a maximum dose

tions on how to meet these goals. In policy for reporting repeat test- for the medication selection;

• Is the laboratory technician

addition to training and in-services, the ing:
following ideas may help implement Continued on page 4
the goals in your facility. required to report this
occurrence to his supervisor
or to the ordering physician?
Goal #2, new requirement – measure, JACHO WEBSITE
assess and, if appropriate, take action
Goal # 3, new requirement – Anyone wishing to review the 2005
to improve the timeliness of reporting,
identify and, at a minimum, National Patient Safety Goals at their
and the timeliness of receipt by the
responsible licensed caregiver, of criti- annually review a list of look- source should access the JCAHO website:
alike/sound-alike drugs used, and click on “National
• When a blood specimen is inad-
cal test results and values.
in your organization, and take Patient Safety Goals & FAQs” under the
equate and lab results are mis- action to prevent errors “Top Spots” heading. For both 2004
leading check the equipment involving the interchange of and 2005 you will find program specific
• When incorrect medication
these drugs. goals. To thoroughly understand each
• Are the manufacturers rec-
that was used:
goal, also review the links to: “Rationale
ommendations being fol- label leads to dispensing of and Interpretive Guidelines” and “FAQs”,
• Check the arrangement of
wrong medication:
• Is there an established poli-
lowed; which includes a complete list of new
look-alike/sound alike drugs.
• Rearrange the bins (not in
cy on how to collect the the medication bins;

NEWS FROM THE • Review the fall assessment
worksheet to ensure it Patient Safety Links
PATIENT SAFETY includes detailed instruc- Interesting Resources To Explore
tions and easily understood, Joint Commission on Accreditation of
CENTER Healthcare Organizations

• Check that documentation is

clearly written definitions;
Feedback and Suggestions complete and appropriate
Sentinel Event Alert: Issue 31, August 31,

Based on Your Reporting providers are notified of any

Revised guidance to help prevent ker-
areas of concern. Sentinel Event Alert: Issue 32, October 6,
continued from page 3 2004
Preventing, and managing the impact of
Goal # 10, new goal for 2005 – anesthesia awareness.
warning to alert the user of
• Evaluate the first element of the
reduce the risk of surgical fires.
a possible medication error American Medical News
when inputting the order

• Is there a paper drape in

fire triangle – the fuel: Vol. 47, No. 30

entry; “Senate Passes Patient Safety Bill”
Change the appearance of Report on latest Senate action on national

• What is the level of drape

use; system for collecting medical error data.
look-alike product names on
the computer screen by
• Select drape material with
Annals of Family Medicine
lint production;
using bold face, color or tall
July/August, 2004

man letters;
• Evaluate the second element of
the greatest fire protection. Two editorials and reports on four primary
Install computer alerts for care patient safety studies:

look-alike medication; “Preventing Errors in Clinical Practice: A

• Is oxygen necessary during

the fire triangle — oxygen use: Call for Self-Awareness”; “A String of
Construct the computer Mistakes: The Importance of Cascade
selection screens and dis- Analysis in Describing, Counting and

• Is the level of oxygen consis-

the procedure; Preventing Medical Errors”; “Event
pensing screens in a way
Reporting to a Primary Care Patient Safety
that will eliminate two simi- Reporting System: A Report From the ASIPS
tent with the patient’s
lar medications from appear- Collaborative”; “Patient Reports of
needs, can the level be low-

Preventable Problems and Harms in Primary
ing consecutively;
• Evaluate the third element of
ered to 30% from 100%? Health Care”.
List the brand and generic
name of the medication in VA National Center for Patient Safety
the fire triangle — the ignition
the computer system and for
• How close to the oxygen is
source: TIPS – official patient safety newsletter of
look-alike, sound-alike med- the Department of Veterans Affairs.
ications note the action of July/August, 2004 – “How to Make the Most

• Can the equipment be

the equipment? of Actions and Outcome Measures”— effec-
the medication. tive actions in response to RCAs and strate-
gies in building outcome measures; includes
moved to another location a practical table of examples.
Goal # 9, new goal for 2005 - reduce
• Can the equipment be
when not in use; September/October, 2004 – “Ensuring
the risk of patient harm resulting from Correct Surgery and Invasive Procedures”.

• When there is a fall after a pro-

• When there is a chance of igni-
placed in standby mode? Premier Safety Share Institute
cedure consider the feasibility of October, 2004
tion during a procedure, ensure “Patient fall rates drop 20% using innova-
using a transport team for
that saline is readily available in tive prevention strategies”: cites study
patient movement off the ward
• Is there active dialogue prior
the operating suite: reported in June, 2004 Joint Commission

• Review the data related to

for tests and procedures: Journal on Quality & Safety (Vol. 30, No.6)
entitled “Take a Second Glance”, describing
to and during the procedure Northwestern U. fall prevention program.
time of day, ward staffing, Includes links to two other fall prevention
between the operating sur-
level of provider for trans- resources:
geon and anesthesia staff re: Premier Safety Institute Fall Prevention
port, type of procedure,
the prevention of surgical Site; State Resources.
ward census and acuity of
• Are saline soaked gauzes or
• Use this information as a
patients; New England Journal of Medicine
sponges used to minimize Two related articles on interns’ work hours
guide to help with the and medical errors in Vol 351, Oct. 28, 2004,
leakage of oxygen if No. 18:
assessment and to help
uncuffed endotracheal tube “Effect of Reducing Interns’ Weekly Work

• Reassess the patient’s condi-

assemble the transport team;
• Is the oxygen used at lowest
is used? Hours on Sleep and Attentional Failures”
(pp. 1829-1837);
tion after a procedure or “Effect of Reducing Interns’ Work Hours on
concentration? Serious Medical Errors In Intensive Care
when there is a change in Units” (pp. 1838-1848).

• When there is a fall after the ini-

the patient’s physical status.

tial fall assessment is completed:

PATIENT system was launched at Wright-
Patterson. Initially, the system was cre-
ments; and, over-all, an increased facili-
ty-wide participation in the review

SAFETY IN ated with Powerbuilder software and

Sybase database. It was converted to a
process. The system has been enthusi-
astically approved in demonstrations

ACTION web-based application using ASP.NET

front-end and Oracle 9i database back-
to clinical gatherings. If the Air Force
Surgeon General’s Requirements
Experiences and end to meet security requirements. It
has the potential for wide area net-
Oversight and Capabilities Council
approves, it will soon be available to
Suggestions From the Field work access, but currently is config- all users of the Integrated Clinical
ured only for intranet access. Any net- DataBase (ICDB).
worked personal computer in the facil-
MEDICAL ity can serve as a records review plat-
form and access records review data.
RECORD Information security is ensured by
REVIEW MADE password access and privileging of BE AWARE WITH
Wright-Patterson Develops The MRRTS database contains a cen-
tralized set of questions.Virtually any
Own System patient care standard that can be
reviewed in the documentation of a
Call for Patient Safety

he medical record in today’s
health care facility is a vitally
clinical encounter can be entered into Newsletters
the database. Since its inception, over
important repository of data.
215 questions have been used by
Review of the medical record yields
insight into quality, compliance, cre-
Wright-Patterson to assess perform-
ance, with no less than 35 questions
T he fourth annual National Patient
Safety Awareness Week, sponsored
by the National Patient Safety
dentialing, individual and institutional
related to patient safety issues. Foundation, is scheduled for March 6-
progress. However, most healthcare
(Examples include: “Appropriate coun- 12, 2005.
facilities struggle with how to effi-
seling for discharge medications was
ciently, systematically review, extract
performed to include potential drug- In preparation for this national educa-
and apply medical records data in
drug and drug-food interactions”; tion and awareness building campaign
addressing patient safety and other
“Abnormal data collected by clinic aimed at improving patient safety at
staff and technicians is addressed dur- the local level, Patient Safety
ing patient’s visit”;“The patient’s Newsletter asks you to join Project
Wright-Patterson Medical Center devel-
assessment includes the identification News Share. We know that some
oped a medical records review system
of learning needs and barriers to learn- MTFs publish in-house patient safety
it believes is the most effective, user-
ing”.) The system makes aggressive use newsletters. If your MTF publishes a
friendly system available. The Medical
of standard reports, which are shared local patient safety newsletter please
Records Review Tracking System
with providers and clinical groups. In send a copy to the Newsletter
(MRRTS) was designed by an in-hospi-
the case of the Patient Safety Group, ( so that we can
tal team: (LtCol. (Dr.) William Venanzi
data generated from MRRTS reports is share your efforts in the winter issue.
(Chair), Ms. Gail Elliott, Medical
used to develop priorities for root Include a brief note telling us how
Records Flight leader, and Mr.Tuan
cause and failure mode/effects analy- often you publish your newsletter, how
Tran, IT Support Contractor), charged
ses, to monitor the effects of interven- you circulate it, and how you think it
with establishing a consistent records
tions, identify trends and suggest contributes to your patient safety
review system to improve the existing
opportunities for improvement. Since efforts.
quality and scope of review and feed-
its inception, MRRTS has been expand-
back.The team focused on the devel-
ed to include in-patient and out-patient Together we can provide a timely
opment of a set of centrally controlled
records review, all treatment areas, response to Patient Safety Awareness
review parameters, including a core
physical therapy and death reviews. Week by sharing our individual com-
group of review questions, to docu-
ment the quality of the medical record munication tools, and working cooper-
Wright-Patterson believes the MERRTS atively to expand our awareness of
and the quality of medical care.
system offers multiple benefits: auto- successful patient safety efforts.
mated, standardized reports for a wide
In May 2000, after eighteen months of
variety of patient care standards; quali-
investigation, and with the hands-on
ty, user-friendly feedback to the entire
involvement of an information technol-
facility and specialized for depart-
ogy support contractor, the MRRTS

INFECTION spotlighting actions to contain the
spread of contagious diseases like the
CONFERENCE CONTROL common cold, strep throat and
influenza is especially important,
CALENDAR MAKES given the national shortage of flu vac-


PATIENTS JCAHO is urging Americans to do
QUALITY IMPROVEMENT IN SAFER three easy things to fight infections:
Clean Your Hands. All healthcare
HEALTH CARE JCAHO Offers Easy providers should review the CDC
hand hygiene guidelines and encour-
December 12-15, 2005
Orlando, Florida Three-Step Campaign age renewed compliance.
Cover Your Mouth and Nose. And remember to wash your hands after.


T he Joint Commission on
Accreditation of Healthcare
Organizations (JCAHO) has joined
Avoid Close Contact. If you are sick
with fever or symptoms of contagious
with a number of other national illness, you place others at risk by
health associations to promote an putting yourself in their presence.
HEALTH CARE easy three-step campaign to help con- Stay home.
February 28-March 2, 2005 trol the spread of infections in health-
San Diego, California care settings and the community this According to Denise Cardo, MD, direc-
winter. JCAHO has focused on infec- tor, Division of Health Care Quality Promotion, CDC: “Preventing the
tion control in the past, issuing a
Sentinel Event Alert in January, 2003 spread of infection in healthcare set-
1ST ANNUAL INTERNATIONAL recommending compliance with the tings protects patients and saves
SUMMIT ON REDESIGNING Centers for Disease Control and lives….Good hand hygiene is espe-
Prevention (CDC) hand hygiene cially important”.
guidelines. This winter, however,
June 8-10, 2005
San Diego, California


Co-sponsored by Office of Assistant
Secretary of Defense for Health Affairs
Patient Safety is published by the Department of Defense (DoD) Patient Safety Center,
located at the Armed Forces Institute of Pathology (AFIP). This quarterly bulletin provides periodic updates
February 13-17, 2005 on the progress of the DoD Patient Safety Program.
Dallas, Texas
DoD Patient Safety Program Office of the Assistant Secretary of Defense (Health Affairs)
TRICARE Management Activity
ACHE CONGRESS ON Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, Virginia 22041
March 14-17, 2005 Please forward comments and suggestions to the editor at:
Chicago, Illinois DoD Patient Safety Center Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
Phone: 301-295-8115 • Fax: 301-295-7217
CONGRESS E-Mail to editor:

Orlando, Florida DIRECTOR, PATIENT SAFETY CENTER: Geoffrey Rake, M.D.
NAVY: Ms. Carmen Birk
AIR FORCE: Lt Col Beth Kohsin