INSIDE: DoD Combat Care Incorporates Patient Safety Fundamentals



Simulation Training at Home, Hands-On Training in Iraq Make System Combat-Ready
eamSTEPPS, the evidence-based team-training system developed by the DoD Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ), is fast becoming an integral part of combat-casualty care in Iraq. The TeamSTEPPS curriculum has been adapted to meet the needs of physicians, nurses, medics and other health-care professionals in the Iraq theatre of operations. Providers are taught fundamental TeamSTEPPS concepts such as briefs, huddles and the SBAR handoff communication model. State-side simulation training prior to deployment and real-time use of TeamSTEPPS in theatre are combining to make TeamSTEPPS a combat-ready tool to improve patient safety at the earliest point of medical intervention.


The story of TeamSTEPPS at war is the story of military medical administrators and providers collaborating to offer wounded warriors the best and safest medical care from the moment of injury. The experiences described below — of the 86th Combat Support Hospital (CSH) in Baghdad and the 947th Forward Surgical Team (FST) training here at home — tell the TeamSTEPPS story best. In the telling, they affirm the power of TeamSTEPPS to improve patient safety and the determination, strength and dedication of the Military Health System to the care of its patients.

Surgeons and support staff from the 86th CSH Task-Force Baghdad. Pictured left to right, front to back: CPT Dena George, COL Peter Napolitano, MAJ Kevin Chung, MAJ Brian Themann; (2nd row) MAJ Jeffrey Henning, MAJ Dawn Elliott, LTC Booker King, MAJ Patrick Hickey, LTC Michael Meyer (blue scrubs); (3rd row) LTC Jon Stineman, MAJ Mark Aierstok, LTC Steven Svoboda, LTC Anthony Allen, LTC Michael Mulreany, MAJ Todd Baker (by sign), MAJ William Ralston, CPT Jason Cohen, COL Richard Stack (blue scrubs).



Patient Safety Week Activities


Call for Patient Safety Awards


Patient Safety Website

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The 86th Combat Support Hospital, Baghdad, Iraq
Bringing TeamSTEPPS to the Front Lines Since February of this year, the 86th Combat Support Hospital (CSH) Task-Force Baghdad has enjoyed the extra TeamSTEPPS advantage in its quest to safely treat and transport the casualties of war in Baghdad. February marked the arrival of COL Peter Napolitano, Director of the MaternalFetal Medicine Fellowship at Madigan Army Medical Center and long-time TeamSTEPPS champion. Prior to deployment for his tour at the 86th CSH, COL Napolitano assessed the use of TeamSTEPPS in theatre. Finding that there was no formal implementation, he explored with Command the possibility of introducing TeamSTEPPS. With the enthusiastic backing of leadership, COL Napolitano worked with the Patient Safety Program’s Health Care Team Coordination Program (HCTCP) to have TeamSTEPPS material shipped to Iraq. He then faced the challenge of how to train trainers and staff in the busiest combat hospital in the world. The traditional TeamSTEPPS two and one half day Train-the-Trainer course and four to six hour Train-the Participant phase clearly would not fit the high acuity CSH environment. Over two weeks of periodic classes, COL Napolitano trained forty-five representatives from every unit of the hospital, fashioning an intense four hour combined fundamentals and instructor curriculum. With this initial cadre of coaches in place, he began a twice weekly concept release program. As each TeamSTEPPS concept was introduced, coaches modeled behavior and staff incorporated and adapted the tool to their particular unit. Currently about one-half of the total CSH staff in Baghdad has received formal TeamSTEPPS training. An active interest in TeamSTEPPS is palpable throughout the hospital. COL Napolitano believes the CSH, despite its challenges and unpredictable routine, is uniquely suited to embrace the TeamSTEPPS system. With their sharp focus on casualty care and single-minded purpose, staff members unite 2

Hospital staff see soldier off to next echelon of care in Balad after stabilization and treatment at the 86th CSH Task-Force Baghdad.

On a typical day the Combat Support Hospital receives several MASCALs with little down time in between. All operating rooms are in use. The transport system is in full swing. Black Hawk helicopters are standing by to move patients to the Air Force’s Expeditionary Medical Group Hospital, the next echelon of care on their journey to Landstuhl and eventually back home. On this day two soldiers arrived at the staging area for transport, accompanied by ICU nurses, who would fly with them and respond to any emergencies in flight. The flight-line check list had been reviewed. The patients were ready for loading. Before they were settled in the chopper, the attending ICU physician unexpectedly arrived at the flight line. She hurriedly explained that she had missed her usual TeamSTEPPS-inspired huddle before the patients left the ICU and that she wanted to review the patients one last time with the nurses. During the huddle she reminded the flight nurses that one of the patients had especially severe respiratory injuries. A special piece of equipment was determined to be necessary should he need to be resuscitated in flight. This equipment, because it is rarely needed, is not included in standard flight resuscitation sets. After the huddle, the crew made a special effort to find one and bring it on board. Fifteen minutes into the thirty minute flight,the soldier suffered a respiratory arrest. The accompanying ICU nurse used the equipment in a successful resusitatation. In this case, the TeamSTEPPS huddle highlighted an important piece of information for this soldier's care. In the combat care setting success is not about a predetermined process, but is achieved by learning the TeamSTEPPS concepts and adjusting them to work in the midst of the unexpected. The ICU physician's huddle on the landing zone, right at the chopper door, underscores the adaptability of TeamSTEPPS tools and their readiness for combat.

around the same goal. They are particularly open to trying new things and are able to learn at an accelerated rate in the somewhat self-contained CSH environment. Deputy Commander of Nursing (DCN) COL Stephen W. Lomax, new to TeamSTEPPS himself, says he was quickly won over to a system he feels improves patient care. His nursing staff is receptive to things they feel give them an advantage, especially in the frequently high-stress atmosphere of the CSH. The practical application and value of TeamSTEPPS in the combat zone has been affirmed in the daily experiences of the 86th CSH. With several hundred confirmed rocket and mortar attacks in the Baghdad area since January 2008, providers have been known to receive two to five massive casualty events (MASCALs) on a given day. The hospital fills and empties daily. Victims receive life-saving surgery and treatment and then are transported to the next echelon of care within one to twenty-four hours. In this extremely high acuity atmosphere an individual patient may be involved in ten to fifteen handoffs. There is an understandably increased risk of losing or overlooking a critical piece of medical information between a soldier’s transport from the battlefield by medical evacuation (MEDEVAC) to the time he or she leaves the CSH from the helicopter landing zone (LZ). TeamSTEPPS tools such as the SBAR, I PASS THE BATON, briefs, huddles, check back and the I’M SAFE check on situational awareness provide structure and reliability in the midst of such intense trauma. As the TeamSTEPPS champion prepares for his June departure, COL Napolitano has great confidence that TeamSTEPPS will become an organic part of the medical side of Operation Iraqi Freedom (OIF). COL Patrick D. Sargeant, Commander of the 62nd Medical Brigade, is an enthusiastic advocate of its widespread use throughout the theatre of operations. COL Napolitano has assembled a strong support staff. MAJ Michelle Munroe, a nurse Midwife from Madigan Army Medical Center serves as Emergency Medicine and Deployment Combat Casualty Research Team (DCCRT) Research Nurse at the 86th. She has been critical to the success of TeamSTEPPS in theatre and will become its Nurse Champion going forward. MAJ Munroe, with the assistance of COL Lomax and LTC Vivian

Ludi, Patient Safety Process Improvement Officer, will expand the TeamSTEPPS training to the five other CSH units, eight Forward Surgical Teams and one Air Force hospital in OIF. With its champions in place, COL Napolitano credits the dedicated health care providers deployed to OIF as the real power behind the TeamSTEPPS difference. In this most challenging of all situations, he explains “TeamSTEPPS provides workable tools to an already strong system. It reinforces good teamwork behavior that good leaders are already doing. TeamSTEPPS formalizes the good work we do and ensures that we do it all the time”.

The 947th Forward Sugical Team
Training at Home to Deploy as a Team The 947th Forward Surgical Team (FST) from the West Hartford Reserve Center participated in the first fully dedicated TeamSTEPPS simulation training March 7-9 at the National Capital Area Medical Simulation Center in Silver Spring, Maryland. Pronounced a “fabulous success” by MAJ Michael Gutman, 947 FST Commanding Officer, team members spent a full day working through scenarios that simulated field experiences from triage to resuscitation to transport.

The 947th FST is in year three of a five year training cycle, thus not in line for the Army Trauma Training Center (ATTC) course which integrates TeamSTEPPS concepts in the intensive trauma curriculum offered to deploying surgical teams. MAJ Gutman, long interested in Crew Resource Management, set out to explore team training options available to the 947th as they hone their clinical skills. He worked with Ms. Heidi King, Director of the DoD Patient Safety Program Health Care Team Coordination Program (HCTCP) and the National Capital Area Medical Simulation Center (Sim Center) staff to develop a TeamSTEPPS simulation experience aimed at teaching team dynamics and communication skills to the FST. In December 2007, HCTCP taught the FST TeamSTEPPS fundamentals in a weekend-long course adapted to support its up-coming simulation training. Upon arrival at the Sim Center on March 7th, the FST received a two hour refresher course, along with an orientation to the Sim Center. Saturday, March 8th was SIM DAY — nine hours of training, broken into three “Days”, each Day representing an increasingly complex combat scenario. Battlefield authenticity was achieved using the Sim Center’s high-tech resources — a Wide-Area Virtual Environment (WAVE) for triage

The 947th Forward Surgical Team “brief”, assigning roles and responsibilities prior to Day 2 of TeamSTEPPS Simulation training.
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training, with front line background, lighting and sound effects; a two-patient Resuscitation Bay and holding area; and a fullyequipped Clinic. Twenty patients had been hired, pre-trained and expertly made-up as

trauma victims for the day. In addition to the regular complement of Sim Center staff, the faculty included three visiting physicians who role-played, observed and critiqued the team’s performance. Further input was pro-

vided using the Sim Center’s computerized monitoring and evaluation process. Debriefs following each “Day”, facilitated by Sim Center staff, encouraged FST members to reflect on their performance. Physician faculty members and a nurse monitor who had been briefed on TeamSTEPPS added their observations, which were detailed and process-directed. With comments such as “I didn’t hear a callback” or “Did you use the huddle”, they kept the focus on teamwork fundamentals. They also challenged the FST members on how they interacted with their role-playing faculty. One physician, explaining that she had been simulating a distracting physician presence, encouraged team members to rely on their teamwork skills especially in the face of stressful, unanticipated challenges. As FST members moved through their various scenarios, both they and the Sim Center staff and faculty agreed that communication improved and the use of TeamSTEPPS-related tools increased. MAJ Gutman believes the combined TeamSTEPPS/Simulation exposure at this time in his FST’s training cycle is beneficial for a number of reasons. The training strengthens the team bonds among members (many of whom are new to the FST); it breaks down barriers to communication inherent in the military hierarchy which at times are impediments to clinical care, especially in high-stress situations; and it integrates clinical skills in the environment where the team will be receiving patients. His goal, says MAJ Gutman, is to try to get the FST members totally comfortable working with each other well before they deploy. Once they are in theatre, surgeons or other officers will be plugged into the team and rotated every few months. In such a fluid environment, where a certain amount of change is built in, the presence of a shared mental model of performance among the forward surgical team members encourages skillful, reliable interaction time after time, regardless of external challenges. This early training of a unified core which has learned to function together will increase the functionality of the FST, the implementation of TeamSTEPPS tools and the safety of patients and providers alike in the real world of combat trauma care.

Members of the 947th FST practicing battlefield triage in the Wide Area Virtual Environment (WAVE) setting of the National Capital Area Medical Simulation Center.

MAJ Michael Gutman, Commanding Officer of the 947th Forward Surgical Team observing teamwork skills while FST members work on a patient in the Resuscitation Bay.



Experiences and Suggestions From the Field

March 2–8, 2008 Observed With Posters, Awards, Games and Patient/Provider Camaraderie

20 MDG: Shaw AFB, South Carolina Poster from Shaw AFB, where the National Patient Safety Week (NPSW) poster contest was inspired by information included in the Ambulatory Patient Safety Goals. Congratulations to TSgt Ollet who received a one-day pass for his first-place effort, shown above.

90 MDG: Warren AFB, Wyoming Capt. Lisa Lee, Clinical Pharmacy Services Chief, 90th Medical Support Squadron, instructs pre-schoolers from the F.E. Warren Child Development Center on the fundamentals of clean hands as part of the 90th MDG NPSW outreach efforts. In addition to hand hygiene, the 90th MDG encouraged patients to share responsibility for satisfactory clinic appointments by bringing a list of medications and by keeping an appointment notebook.

27 SOMDG: Cannon AFB, New Mexico Pediatric dosing spoons, pill containers and poison control brochures were displayed and distributed during National Patient Safety Week in the atrium of the 27SOMDG. Staff observed the week with daily patient safety emails and an electronic patient safety Trivia Contest.

Munson Army Health Clinic Fort Leavenworth, Kansas Munson Army Health Center, Fort Leavenworth, KS recognized three services for outstanding achievement in Patient Safety during National Patient Safety Week: Radiology — highest near miss/good catch reporting; Laboratory — highest over-all reporting of Patient Safety events; Operating Room — 100% compliance with The Joint Commission’s Universal Protocol for all surgical procedures. Each Service was presented with a specially designed plaque featuring the DoD and AMEDD crests. Pictured are staff members from the three clinics.

377 MDG: Kirtland AFB, New Mexico Terry Duke, Patient Safety Manager, meets Ms. Doris Joy, the Medical Group’s Health Benefits Advisor to plan the distribution of the National Patient Safety Foundation brochure on the patient’s role in making healthcare safer. During Safety Week, the brochure was given to patients while they waited for appointments and prescriptions and explored their TriCare benefits.

35 MDG: Misawa AFB, Japan Patient Safety Manager Paul Sayles is interviewed by the local Air Force Network morning DJ about Patient Safety Week and medication reconciliation. The station aired spot patient safety announcements during Patient Safety week. The 35 MDG also hosted a staff treasure hunt for patient safety errors and sponsored a bulletin board contest featuring application of patient safety goals within the hospital units.

The Office of the chief Medical Officer (OCMO) at TRICARE Management Activity (TMA), sponsor of the Department of Defense (DoD) Patient Safety Awards, is calling for submissions for the 2008 Patient Safety Awards. Now in their sixth year, the Patient Safety Awards recognize efforts designed to improve the care delivered within the Military Health System. The deadline for awards submissions is SEPTEMBER 10, 2008. The awards will be presented at the annual Military Health System (MHS) Conference, which is scheduled from November 30 to December 5, 2008. Access the Patient Safety Website: to download an Application Guide.



March 2–8, 2008 Observed With Posters, Awards, Games and Patient/Provider Camaraderie
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374 MDG National Patient Safety Week Treasure Hunt List
8. Locate your nearest Crash cart. What items are kept in Drawer C? 1. List the location of at least two fire extinguishers in or closest to your department.

______________________________________________ ______________________________________________
2. What is the middle initial of the Patient Safety Manager?_________ 3. Locate a Patient Rights Poster. What is the 4th right listed?

_________________________________________________________ 9. What is the memo called to report an unusual occurrence, a medication error or clinical mishap? (Hint: mnemonic describing situation, recommendation, follow up and trends)?___________ 10. Where is the Medical Control Center set up in a disaster? (Hint: The Disaster Team Chief Emergency Plan binder).

______________________________________________ ______________________________________________
4. What MDGI empowers staff to notify his/her supervisor if he/she has conflict caring for a patient? What is the MDGI and paragraph number? (Hint: staff rights and organization ethics)

______________________________________________ ______________________________________________
11. Find the TeamSTEPPS™. What is the tool listed on page 27 (17 for 1st Edition pocket guide) used to help communicate critical information that requires immediate attention and action requiring a patient’s condition? (Hint: can be used during hand-offs) ______________________________________________________

______________________________________________ ______________________________________________
5. If applicable, where is the main 02 shut-off within your department? Who can shut it off in the event of an emergency?

______________________________________________ ______________________________________________
6. When is the next Hospital Newcomer’s Orientation held? _________

12. How long do you have to complete an Event Report? (Hint: MDGI 44-138 Patient Safety Program)____________________________ 13. How do you know if a provider or surgeon is privileged to perform a specific procedure? (Hint: Can Dr. Pike do an appendectomy?)

7. Where is the shredder closest to your department?


______________________________________________ ______________________________________________

3 MDG Elmendorf AFB, Alaska Jeopardy host Jim Cahill, Director of Performance Improvement, listens to an answer from Capt Corey during a Squadron Jeopardy game on March 5th. The game was designed to help staff prepare for a summer Joint Commission/ HIS inspection, with questions and answers related to Joint Commission hot topics and general HIS information. Staff response was so enthusiastic that Executive Leadership has requested another game be scheduled in May.

Naval Hospital, Bremerton Bremerton, Washington Commanding Officer Catherine Wilson officially opens the Bremerton Patient Safety Circus by cutting the ribbon to the quarterdeck display. Inside, patients and staff found circus themed boards and props with patient safety information, a Patient Safety Goal toss-a-cross game and a Circus “Side Show” featuring a petri dish sampler showing pre and post hand-washing germ growth.

374 MDG Yokota AB, Japan The 374th MDG staged a facility-wide treasure hunt for patient safety-related clues during their National Patient Safety Week observance. The Pediatrics Department won the contest with 100% participation from doctors to administrators. Stress balls and pens with the logo "Deliver Safe, Compassionate Quality Healthcare" were given to all staff members during the week.

PATIENT SAFETY WEBSITE Busier and Better Than Ever
As the revised Patient Safety Website marks its first year in operation, a review of its use and improvements underscores the integral role it plays in communicating key elements of the DoD Patient Safety Program (PSP). Soon after its April 2007 launch, the website recorded 2,000 plus visits per month. March 2008 saw over 9,000 visitors, representing world-wide contacts ranging from English-speaking countries like Australia, Canada and the U.K., to the more exotic locales of Europe, Asia and the Middle East. Although the greatest percentage of visitors (38%) come from U.S. Military sites, 29% represent U.S. commercial users, with smaller numbers from non-profit organizations and U.S. government sites. Information relating to TeamSTEPPS is frequently accessed, as is the DoD Fall Reduction Tool and PSP education modules. For those users who are part of the DoD Military Health System, the website offers entry to the full range of PSP initiatives, achievements and plans. User-group log-in capability is now an established function on the website. Interactive features have become a reality. The TeamSTEPPS Learning Action Net6

work (LAN) regularly posts its agenda and power-point presentations on the website for participants to access during conference calls linking any number of remote sites. The Patient Safety website is not resting on its accomplishments. Under the direction of PSP Webmaster/Developer Vienkhanh (Khanh) Nguyen the site continues to add content and new features. Going forward, look for an even more user-friendly, visually arresting format. "It's all about the people and making it easier for them to find the information they're looking for", says Webmaster Khanh.
Website usage by Country for March 2008

Published quarterly by the Department of Defense (DoD) Patient Safety Center to highlight the progress of the DoD Patient Safety Program.

Skyline 5, Suite 810, 5111 Leesburg Pike Falls Church, Virginia 22041 703-681-0064
Forward comments and suggestions to: DoD Patient Safety Center Armed Forces Institute of Pathology 1335 East West Highway, Suite 6-100 Silver Spring, Maryland 20910 Phone: 301-295-7242 Toll free: 1-800-863-3263 DSN: 295-7242 • Fax: 301-295-7217 E-Mail: Website: E-Mail to editor:

DoD Patient Safety Program Office of the Assistant Secretary of Defense (Health Affairs) TRICARE Management Activity

US Military 38% US Commercial 20% Network 15% Unresolved/Unknown 15% Non-Profit Organization 5% US Educational 3% US Government 1% Australia 1% Other 2%