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Patient Safety Event Reporting

All facilities in the Military Health System (MHS) Direct CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”direct care system voluntarily report their patient safety events to the Patient Safety Program. Reporting is one of the key components in the MHS' effort to achieve high reliability, continuously improve and provide the safest patient care possible. Reported events include all degrees of harm for those that reach the patient. Reported events also include near misses and unsafe conditions which do not reach the patient. The reporting of events not reaching the patient allows the Patient Safety Program to analyze the sequence of events that may potentially lead to errors before they affect patients. The Patient Safety Program, through the Patient Safety Analysis Center analyzes the reported data along with additional data sources and provides cumulative data reports and feedback to the military treatment facilities (MTFs) through the Services. These analyses are then utilized to design and develop programs and tools to assist the MTFs in reducing preventable harm and improve safety throughout the direct care system. In contrast to other health care systems, the dental program is an integral component of our health care system and dental events are included in our reporting and analysis in addition to medical events.

The table below shows patient safety reporting in FY 2014, as compared with FY 2013, stratified by harm classification.

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Showing results 16 - 26 Page 2 of 2

MHS Patient Safety Spotlight

Article

6/1/2016

The MHS Patient Safety Spotlight is a new resource designed to highlight best practices and interesting initiatives that come from the field and are worthy of being shared across the enterprise. This resource features data-driven examples of improvement and case studies that tackle specific problems with specific solutions.

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Patient Safety, eBulletin, Products & Services, Patient Safety Event Reporting, Patient Safety & Quality Academic Collaborative, Advancement toward High Reliability in Healthcare Awards Program

HRO Corner: The Oro™ 2.0 High Reliability Organizational Maturity Pilot Program and the Military Health System

Article

6/1/2016

Achieving a cultural transformation across the Military Health System (MHS) toward high reliability requires a mindset that aligns our individual and organizational actions with our vision for the future. A future that embraces quality and a culture of safety thoroughly, completely and across all levels of the enterprise.

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Patient Safety, eBulletin, Products & Services, Patient Safety Event Reporting, Patient Safety & Quality Academic Collaborative, Advancement toward High Reliability in Healthcare Awards Program

MHS Patient Safety Data Snapshot

Article

6/1/2016

The new MHS Patient Safety Data Snapshot is a monthly compilation of two types of patient safety data 1) Sentinel Event (SE) notifications submitted to the Patient Safety Analysis Center (PSAC); 2) Anonymous, voluntarily reported patient safety events via the web-based incident reporting system known as PSR.

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Patient Safety, eBulletin, Products & Services, Patient Safety Event Reporting, Patient Safety & Quality Academic Collaborative, Advancement toward High Reliability in Healthcare Awards Program

Patient Safety in Action: U.S. Naval Hospital Guam is Selected as a 2016 Stand Up for Patient Safety Program Management Award Winner

Article

6/1/2016

A registered nurse tends to a patient May 3.

The DoD Patient Safety Program congratulates U.S. Naval Hospital, Guam, for its National Patient Safety Foundation (NPSF)’s 2016 Stand Up for Patient Safety Management Award! Proudly representing the Military Health System (MHS), U.S. Naval Hospital, Guam, received this prestigious accolade for the implementation of a program which significantly improved medication reconciliation in its Family Medicine Clinic.

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DoD PSP Treasure Chest: June Edition

Article

6/1/2016

The June edition of the DoD PSP Treasure Chest highlights TEAM UP, I PASS THE BATON, TeamSTEPPS® and the Partnership for Patients (PfP) Sustainment Guides.

Welcome to the June edition of the DoD PSP Treasure Chest! Each and every month, we will be sharing resources to help you execute your day-to-day patient safety activities easily and effectively. Please visit us often and get access to tools and information developed with you, our committed MHS patient safety champions, in mind!

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Patient Safety in Action: An Interview with Dr. Ashok Ramalingam, Chief of the Patient Safety Analysis Center (PSAC) – A Leadership Perspective

Article

4/1/2016

Image of Dr. Ashok Ramalingam, Ph.D., M.S, B.Pharm, D.Pharm, R.Ph; Chief, Patient Safety Analysis Center (PSAC).

We recently interviewed Dr. Ashok Ramalingam, Ph.D., M.S, B.Pharm, D.Pharm, R.Ph, CPPS, and new Chief of the PSAC, to learn about his experience, background, perspectives on patient safety and how these factors set a standard for his leadership style and the goals he has for the PSAC.

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Continuing Education Update I: TeamSTEPPS® Continuing Education Credit Planning Checklist

Article

3/1/2016

A group of MHS professionals attends a class to expand their patient safety skill set. (U.S. Navy photo by Mass Communications Specialist 1st Class Matthew N. Jackson/Released)

When planning TeamSTEPPS Train the Trainer and Train the Staff activities, there are several continuing education (CE) accreditation requirements that must be met in order for the course and the attendees to be eligible for formal CE credit. Please use this checklist as a compliment to the TeamSTEPPS Course Coordinator Guidance to help ensure those mandatory requirements are met.

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Continuing Education Update II: Types of TeamSTEPPS Train the Trainer CEs Available via the DoD Patient Safety Program Online Registration Center

Article

3/1/2016

a group of MHS patient safety professionals attend a TeamSTEPPS training in order to more effectively engage their patients. (Photo by 2nd Lt. Tracci Dorgan)

The DoD PSP team is now able to offer eight types of CE credit for TeamSTEPPS Train the Trainer and Train the Staff activities based on attendee eligibility and provision of necessary requirements by the attendee.

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Feature: Patient Safety Awareness Week (PSAW) 2016: United for Patient Safety

Article

3/1/2016

In 2016, Patient Safety Awareness Week (PSAW) will take place 13 March through March19. PSAW is a campaign of great importance to the DoD Patient Safety Program; this is because it is through this type of effort that patient safety champions across the Military Health System (MHS) are able demonstrate their commitment to delivering the highest quality of care and ensuring that our patients’ needs are always addressed.

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HRO Corner: Understanding the "Deference to Expertise" High Reliability Organization Guiding Principle

Article

3/1/2016

MHS health care professionals consult with each other to reach the best solution for their patient. (U.S. Air Force photo by Tech. Sgt. Francisco V. Govea II/ Released)

In March, we are taking an in-depth look at the Deference to Expertise High Reliability Organization (HRO) principle and how it applies to what you do to keep your patients safe on a daily basis. This principle reminds us that HROs are set up so that organizational hierarchy is not what determines who has the authority to make decisions to deal with an issue but rather skill level and expertise with that issue. Leaders listen to and value the input of those subject matter experts regardless of their title or position. Indeed, it is knowledge and skill level that determine who (or what team) is the subject matter expert – not rank or seniority.

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Patient Safety Spotlight: Patient Safety and Patient-Centered Care

Article

3/1/2016

An MHS health care provider engages and tends to a patient in need of treatment. (Photo by PO1 William Parker)

March is an important month for patient safety as it is the month that we acknowledge Patient Safety Awareness Week (PSAW) – a campaign that highlights the role patient safety champions play in ensuring that patients are not only safe but also respected every time they receive care. In other words, PSAW is about patient engagement; it is a call to step into the role of our patients, see things from their perspective and recognize how we, as patient safety champions, can make a difference in our patients’ lives.

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Showing results 16 - 26 Page 2 of 2