INSIDE: DOD Patient Safety Pilot Test Page 2
Patient
Safety
A quarterly newsletter to assist DoD hospitals with improving patient safety
The Military Health System Patient Safety Program will address the challenge of reducing medical
error and improving patient safety throughout the medical treatment facilities.
Patient Safety Program in
the Military Health System
Why the Patient Safety Program Exists
P resident William Clinton pro-
posed on February 22, 2000
that hospitals undertake a national effort
to publicly report medical errors result-
ing in death or serious injury. This initia-
tive followed the release by the Institute
of Medicine of a groundbreaking report
that estimated up to 98,000 patients in
the United States die needlessly each year
as a result of medical errors. This fa-
tality total exceeds the number of annual
deaths (62,271) from AIDS, motor vehi-
cle accidents, and breast cancer com-
bined. While there is much debate as
to the accuracy of the estimate, all agree
that medical error is a problem that must
be addressed.
(Continued on page 2)
SUMMER 2001
SUMMER 2001
Page 2 Annenberg Conference
Page 3 Legal Corner
Page 3 Calendar
Page 4 Teamwork
Welcome!
...to the very first issue of the
PATIENT SAFETY - the Military
Health System Patient Safety
Center Quarterly Newsletter.
T his newsletter is dedicated to the promotion
of the Military Health System Patient Safety
Program (MHSPSP). Our goals are to assist military
health care professionals to promote patient safety,
reduce medical errors and increase awareness of
patient safety issues and strategies.
Each issue of PATIENT SAFETY will contain the
latest information on the MHS patient safety initiatives
and activities. We will keep you informed of upcom-
ing events and training schedules related to patient
safety and will provide links to related articles and
websites. Standing features of PATIENT SAFETY will
include "The Legal Corner" – information on perti-
nent legal considerations – and "Patient Safety In
Action" – case studies of composite safety failures
and strategies for improvement.
We strongly encourage contributions from our read-
ers. This Newsletter is your newsletter - a collaborative
forum for all DoD facilities and health care profession-
als to share patient safety information, experiences and
strategies. Please help us keep you informed.
You can subscribe to PATIENT SAFETY by clicking on
www.afip.org/Departments/PSC/Index.html or by
emailing PSNewsletter@afip.osd.mil.
Military
Health
System
(continued from page 1)
Following the President’s proposal, the
DoD Patient Safety Working Group was estab-
lished to develop a non-punitive patient safety
reporting program within the Military Health
System (MHS). The Group was further tasked
with developing a Patient Safety Center (PSC)
at the Armed Forces Institute of Pathology
(AFIP) and a patient safety program within
each of the military treatment facilities
(MTFs.) From October 2000 to March 2001,
the Group tested the Patient Safety Reporting
System with data from five pilot sites.
The Patient Safety Center at AFIP became
operational in April 2001. One of its most
important tasks is collecting and analyzing
patient safety information from all MTFs.
Annenberg
Conference
Seminar Highlights
M embers of the DoD Patient Safety
Working Group were among the
600 plus attendees at the 3rd Annenberg
Conference on Patient Safety, held in St. Paul,
MN May 16-18, 2001. This year’s meeting
built on the highly successful 1996 and 1998
Annenberg conferences, which were impor-
tant early events in the growing study of
health care error and patient safety.
The conference theme, "Let’s Talk: Com-
municating Risk and Safety in Health Care,"
focused on the importance of com-munication
in creating a blame-free health care culture
accountable for patient safety. Speakers at
the conference highlighted the complex, col-
laborative nature of communication and the
seminal role it plays in all aspects of health
care – from physician-patient interactions
to the dense web of understanding necessary
among all members of the health care team.
On the basis of this data, the Center will sug-
gest changes that may need to be instituted
in systems and processes to improve per-
formance and reduce the risk of future
injuries to patients.
The Patient Safety Program presents the
MHS with the opportunity to become a leader
in the field of patient safety. Building a non-
punitive "culture of safety" depends upon the
continuous efforts of everyone involved with
patient care and will succeed only with the
cooperation and active participation of every
facility and professional in the MHS.
Admitting and reporting mistakes re-
quires personal courage, active responsibility
and trust in the system. The impact of the
Patient Safety Program has enormous poten-
tial, but its success requires the resolve to
change at all levels of the military health
care system.
The conference included lectures, interac-
tive sessions and exhibits. The Department of
Defense Patient Safety Program was one of the
featured exhibitors. Professionals from all
over the country visited the exhibit, and there
was widespread interest in the DoD patient
safety initiatives. For more information visit
www.mederrors.org.
DoD Patient
Safety Pilot
Test
History and Results
F ollowing the Institute of Medicine
(IOM) report in November 1999, the
Military Health System Patient Safety Program
(MHSPSP) was established. In October 2000,
DoD, through its Patient Safety Working Group,
began a six month pilot test of this program.
The MHSPSP conducted its first training
session at the USUHS with four Washington,
DC sites and Nellis Air Force Base in Nevada.
2
Patient Safety Links
INTERESTING WEBSITES FOR YOU
TO EXPLORE.
ARMED FORCES INSTITUTE OF PATHOLOGY
PATIENT SAFETY CENTER:
www.afip.org/Departments/PSC/Index.html
ITS MISSION: To promote patient safety
in military health facilities.
SPECIAL INTEREST: Links to other sources
AGENCY FOR HEALTHCARE RESEARCH
AND QUALITY (AHRQ):
www.ahrq.gov
ITS MISSION: Lead federal agency on
quality of care research.
SPECIAL INTEREST: Medical Errors &
Patient Safety section
JOINT COMMISSION ON ACCREDITATION
OF HEALTHCARE ORGANIZATIONS:
www.jcaho.org
ITS MISSION: To improve safety and
quality of care through the provision of
accreditation and related services that
support performance improvements in
health care.
SPECIAL INTEREST: Free subscription to
newsletters and news releases
NATIONAL PATIENT SAFETY FOUNDATION:
www.npsf.org
ITS MISSION: To improve patient safety
in the delivery of health care.
The pilot project collected reports of adverse
events and near misses from these sites from
October 2000 through March 2001 and sent
the information to the central registry at the
Armed Forces Institute of Pathology (AFIP)
where it was compiled and analyzed. AFIP
produced several reports for the Patient
Safety Working Group and for the involved
sites tracking the progress of the pilot test.
Feedback from participating hospitals
has been positive. Providers report that the
process is an easy one to follow, and the root
cause analysis procedure is helpful in target-
ing areas that need modification to prevent
further errors.
Based on the success of the pilot study,
the MHSPSP plans to begin roll-out training
sessions in late summer. The first training
session is scheduled July 31 through August
2, 2001 at the Uniformed Services University
of the Health Sciences in Bethesda, Maryland.
On-line registration and specific information
on further training sessions can be obtained
by accessing the Patient Safety Center link
on the AFIP website at:
www.afip.org/Departments/PSC/Index.html.
Patient Safety
in Action
Experiences and
Suggestions from
the field
E ach issue of Patient Safety will devote
this space to teaching examples and
case studies pulled from literature or actual
experience in military treatment facilities. If
the Patient Safety Program is to be truly effec-
tive, the lessons learned from the reporting
system must be shared. Readers will find
suggestions for improved practice here and
are encouraged to consider implementing
recommended actions.
This first column shares experience,
insights and suggestions from the Mike
O’Callaghan Federal Hospital, one of the
facilities involved in the pilot test of the
Patient Safety Program. This facility found
that the reporting requirements of the
Program were easily integrated into their
existing QM/RM system. The Patient Safety
Manager assumed responsibility for complet-
ing monthly reports. Over the six months of
the pilot study, O’Callaghan saw a twenty-fold
increase in reports of near misses.
The hospital established a Patient Safety
Function – an interdisciplinary team to
review events and actively promote a culture
of patient safety. The DoD has also imple-
TM
mented MedMarx, a comprehensive tool for
tracking and trending events. MedMarx is an
TM
Internet-based anonymous, medication error-
reporting system administered by the United
States Pharmacopoeia (USP). Currently,
TM
MedMarx is in use at approximately 100 DoD
medical treatment facilities worldwide.
Initiatives such as these have helped the hos-
pital staff refocus on patient safety issues and
become excited about the potential of the
Patient Safety Program.
The experience of O’Callaghan revealed
challenges for all facilities to consider.
Helping staff to understand the non-punitive
aspect of the Program and the patient disclo-
sure requirements requires consistent re-
LEGAL
Corner
enforcement. Coordination with higher levels
of command is necessary to ensure that all
instructions promote the non-punitive culture
without conflict. Comprehensive, automated
reporting tools will encourage efficiency
and involvement.
The MHS Patient Safety
As other facilities prepare for training
and implementation of the Patient Safety Pro- Program introduces a funda-
gram, the experience of Mike O’Callaghan mental change in the approach
Hospital offers evidence of what can be expect- to error causation and preven-
ed and how to maximize a smooth and suc-
cessful integration in your facilities. Thanks
to Patient Safety Representative Lt. Col. Beth
tion by shifting the focus from
individual mistakes to designing
safer systems to prevent future
Kohsin for her contribution to this article. errors. The Patient Safety Pro-
gram incorporates four legal
elements which re-enforce this
Conference new focus.
The system is Non-punitive.
Calendar Information derived from patient
safety reports is generally limit-
ed to purposes of improving sys-
DOD PATIENT SAFETY
PROGRAM TRAINING tems and processes. Reports to
7/31-8/2/01 the Patient Safety Center contain
USUHS, Bethesda, MD only de-identified information
regarding health care providers
DOD PATIENT SAFETY and patients.
PROGRAM TRAINING The mandate of the Patient
8/1-8/3/01 Safety Program is Preventive.
USUHS, Bethesda, MD The reporting system has been
adopted so that systemic factors
DOD PATIENT SAFETY can be identified and corrective
PROGRAM TRAINING
action can be implemented.
8/14-8/16/01
All Patient Safety Program
Chesapeake,VA.
records and databases, including
the Patient Safety Registry at
QUIC Task Force Summit
On Practices the AFIP, are Confidential med-
9/5-9/7/01 ical quality assurance records,
Washington, DC protected under 10 USC 1102.
To Improve Patient Safety In cases of serious medical
errors, the Patient Safety Pro-
DOD PATIENT SAFETY gram requires that the patient
PROGRAM TRAINING or appropriate family members
9/18-9/20/01 be Informed. This shared infor-
San Antonio, Texas mation is not a legal admission,
nor does it obligate the govern-
To confirm training dates and register ment in relation to any future
on-line access: legal claim.
www.afip.org/Departments/PSC/index.html
3
Teamwork: MEDTEAMS has been tested in the emer-
gency department environment and plans to
teamwork can lead to improvements in patient
safety. The MHS Patient Safety Program will
an begin implementation in labor and delivery
and other high stress medical departments.
continue to explore teamwork training
opportunities and make them available to
Important Evidence suggests that improvements in military facilities.

Part of
Preventing
Medical
Errors
The Institute of Medicine,
in its landmark report on
medical errors, recommended
interdisciplinary team training
for providers as one of the tools
to promote patient safety.

P atients are routinely seen by a team

of health care providers. Commu-
nication and effective interaction among
team members are critical in assuring the
delivery of safe patient care. When team- Communication and effective interaction among team members are critical in assuring the delivery of
safe patient care.
work and communication break down, the
potential for medical errors increases.
The MHS, heeding the importance of
teamwork and communication, has wel-
comed two team-training methods into its
facilities – MEDICAL TEAM MANAGEMENT
(MTM) and MEDTEAMS. Both programs Patient
Safety
are based on aviation team research and
focus on developing effective teamwork and
communication to prevent medical errors.
MTM originated at Eglin Air Force Base
in 1998 as a direct response to a catastroph- Patient Safety is published by the Department of Defense (DoD) Patient Safety Center,
ic medical error. In its four-hour teamwork located at the Armed Forces Institute of Pathology (AFIP). This quarterly bulletin provides periodic updates
and communication training, MTM focuses on the progress of the Tri-Service Patient Safety Program at all military medical treatment facilities.
Please forward comments and suggestions to the editors at:
on seven critical success elements: Policy
and Regulations, Command Authority, DoD Patient Safety Center
Communication, Workload Performance, Armed Forces Institute of Pathology
Available Resources, Situational Awareness 1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
and Daily Operating Strategy. More than Phone: 301-295-8115 Fax: 301-295-7217
E-mail: PSNewsletter@afip.osd.mil Website: to www.afip.org/Departments/PSC/index.html
1500 people have received MTM training
and their responses to the training have CHAIR, DoD PATIENT SAFETY WORKING GROUP: Capt. Frances Stewart, MC, USN
been overwhelmingly positive. SERVICE REPRESENTATIVES:
ARMY COL. Judith Powers, AN
MEDTEAMS, a program designed and NAVY Ms. Carmen Birk
coordinated by Dynamics Research AIR FORCE Ms. Sarah Tackett, CPHQ
PSC COORDINATOR: Richard L. Granville, M.D.
Corporation (DRC), is implemented in three PATIENT SAFETY BULLETIN EDITORS: Jennifer Walters, J.D.
phases – a site assessment, implementation Phyllis M. Oetgen, J.D., MSW
and training plan, and ongoing consultation.