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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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DoD PSP Treasure Chest: August Edition

Article

8/1/2016

Ensign Joshua Mondloch, a nurse assigned to Naval Medical Center San Diego, takes notes in the cardiology in-patient ward. More than 1,000 active duty and civilian nurses provide patient care throughout the medical center. (Photo by Mass Communication Specialist Second Class John O’Neill Herrera)

Welcome to the August 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! This month we highlight the following resources: Patient Activation Resource Guide, Ask Me 3® Brochure, On-Demand e-Learning Courses, and Facebook Page.

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Patient Safety in Action: The I’M SAFE TeamSTEPPS® Checklist – An Exercise in Openness and Transparency with your Team

Article

8/1/2016

NEWPORT NEWS, Va. (Apr. 14, 2016) -- During a General Quarters training exercise, Sailors assigned to Pre-Commissioning Unit Gerald R. Ford's (CVN 78) medical response team, simulates care and treatment for common injuries. This ship-wide general quarters drill focused on damage control and emergency responses and is a significant step in certifying the crew as they train to fight and take delivery of the ship.(U.S. Navy photo taken by Mass Communication Specialist 3rd Class Matthew R. Fairchild/Released)

The connection between transparency and high reliability is one that touches many aspects of what we do as MHS patient safety professionals. We strive to be transparent in the way we share information with our patients – working with them as partners in their care and informing them of what we do openly and visibly. We are also transparent about our MTFs progress towards high reliability so that we can continue marching towards our goal of zero patient harm with efforts such as the Patient Safety Culture Survey. Another way that we, as MHS patient safety professionals, can display transparency on a daily basis is by using tools such as the I’M SAFE TeamSTEPPS Checklist.

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HRO Corner: The Patient Safety Culture Survey Resource Guide – An Overview

Article

8/1/2016

Soldiers from the 399th Combat Support Hospital, 804th Medical Brigade, 3d Medical Command (Deployment Support) watch video footage of their performance during an exercise held April 2, 2016 at the Mayo Clinic Multidisciplinary Simulation Center in Rochester, Minnesota. The unit's every move was recorded at the facility, which allowed them to review and improve their performance throughout the course of the exercise. During the exercise, the unit, which is based out of Fort Devens, Massachusetts, practiced the Team Strategies and Tools for Enhanced Performance and Patient Safety, or TeamSTEPPS, model of patient care. TeamSTEPPS is a framework implemented by the Department of Defense to optimize performance of military medical teams and reduce communication errors that can result in improper patient care. (Photo by: Staff Sgt. Andrea Merritt)

The DoD is on a journey to transform the Military Health System (MHS) into a high reliability organization (HRO) to ensure safe, reliable care for all of its patients and their families. This transformative shift is one that requires a laser-sharp focus by every one of us – leadership and frontline staff – to identify high-risk situations before they lead to an adverse event. To make this possible, prevention and performance improvement must become intrinsic elements of what we do on a daily basis. First, however, we must understand the progress each of our Military Treatment Facilities (MTFs) is making towards the high reliability goal.

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MHS Patient Safety Spotlight

Article

8/1/2016

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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Feature: Transparency, High Reliability and Patient Safety

Article

8/1/2016

Senior Airman Wesley Hong, 60th Medical Diagnostics and Therapeutics Squadron picture archiving communication system administrator, reviews patient imagery May 25, 2016, at David Grant USAF Medical Center at Travis Air Force Base, Calif. Hong works in the hospital's PACS department, which is the largest in the U.S. Air Force. The department is responsible for ensuring the accuracy of health records for medical facilities at 19 bases, including clinics in Afghanistan. (U.S. Air Force photo by Tech. Sgt. James Hodgman)

On any given day, Military Health System (MHS) patient safety professionals are working tirelessly to ensure they provide the highest quality of care to their patients. Driven by a high level of dedication, MHS patient safety professionals know that our patients are the single most important part of our mission and we must serve our patients in an open and transparent way.

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MHS Patient Safety Data Snapshot

Article

8/1/2016

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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MHS Leadership Engagement Toolkit

Training Material

7/14/2016

The Leadership Engagement Toolkit was designed to help healthcare leaders assess gaps in their safety culture, engage key influencers for change, set goals for targeted improvement, implement proven safe practices, and reinforce key behaviors to ensure high-reliability performance for improvement. There are two sets of evidence-based best practices (“strategies”): Executive Leadership and Frontline Physician Leadership. The practices focus on what the practice is, why it is used, and how to implement it. There is also a "How to Guide" that focuses on getting started, equipping leaders as coaches, and making and measuring progress.

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Patient Safety in Action: The DoD Patient Safety Program Announces the 2016 Quality and Patient Safety Awards

Article

7/1/2016

Across the Military Health System (MHS) patient safety professionals work arduously to elevate the care they provide to their patients. The 2016 Quality and Patient Safety Awards program recognizes such hard work and relentless focus on delivering excellence every single day.

Every step Military Health System (MHS) patient safety professionals take towards achieving high reliability is worthy of praise and recognition. Today more than ever, our commitment to excellence in our day-to-day activities is absolutely crucial. For this reason, the DoD PSP team is excited to announce that we will soon begin accepting submissions for the 2016 Quality and Patient Safety Awards.

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Feature: TeamSTEPPS® and High Reliability: An Overview of the 2016 National TeamSTEPPS Conference

Article

7/1/2016

Ms. Heidi King, chief of the Patient Safety and High Reliability Initiatives Office, at the 2016 TeamSTEPPS® National Conference opening up the DoD two-day session titled “The“Military Health System (MHS) Across the Globe….Don’t Stop Believing in Zero Harm”.

The 10th Annual National TeamSTEPPS Conference – an event designed to highlight strategies and techniques to effectively implement and sustain TeamSTEPPS in today’s ever-evolving health care environment – was held 7-10 June, 2016 in Washington, D.C. Welcoming over 700 health care industry professionals and experts, the National TeamSTEPPS conference spotlighted the value of TeamSTEPPS across clinical and non-clinical settings both in the civilian and military space. Addressing a wide range of topics – with over 30 presentations and workshops on subjects ranging from “TeamSTEPPS 101” to “TeamSTEPPS: The Vehicle to Drive your Metrics in the Right Direction,” “The Answer is in the Room: Using TeamSTEPPS to Problem Solve and Reinvigorate Struggling Teams” and “TeamSTEPPS in Times of Transformational Change” – the 2016 TeamSTEPPS National Conference provided attendees the ability to delve into the TeamSTEPPS framework and its application into all aspects of health care and patient safety.

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MHS Patient Safety Spotlight

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7/1/2016

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Military Health System (MHS) Patient Safety Culture Survey Update

Article

7/1/2016

Patient safety professionals across the Military Health System (MHS) work eagerly as teams to deliver excellence and high quality care. By completing the 2016 MHS Patient Safety Culture Survey earlier this year, MHS patient safety champions voiced their opinions and contributed to patient safety improvements in their facilities to optimize the care we provide every day. In this picture, the Army Reserve Medical Command team observes Soldiers of the 399th Combat Support Hospital, 804th Medical Brigade, 3rd Medical Command (Deployment Support) as they conduct an exercise at the Mayo Clinic Multidisciplinary Simulation Center in Rochester, Minnesota. Photo by: Staff Sgt. Andrea Merritt.

Starting in February through mid-April, Military Health System (MHS) staff at Military Treatment Facilities (MTFs) worldwide were asked to complete the 2016 MHS Patient Safety Culture Survey (Culture Survey). The purpose of the Culture Survey was to assess staff perceptions of patient safety at their MTFs.

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DoD PSP Treasure Chest: July Edition

Article

7/1/2016

Military Health System (MHS) patient safety champions work tirelessly to deliver high quality care to their patients. The DoD PSP Treasure Chest provides you with information, tools and the resources you need to help you execute your patient safety activities effectively and easily. This month, access the SBAR toolkit, the Medical Team Performance Assessment Tool (MTPAT), the Patient Safety Learning Center (PSLC) and the Patient Safety Reporting (PSR) eLearning course. Photo by: Robert Whetstone.

Welcome to the July edition of the DoD PSP Treasure Chest! This month, we highlight the SBAR toolkit, the Medical Team Performance Assessment (MTPAT) tool, the Patient Safety Learning Center (PSLC) and the Patient Safety Reporting (PSR) eLearning course. 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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HRO Corner: Measuring the Effectiveness of the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) – U.S. Army Medical Command Implementation

Article

7/1/2016

The DoD PSP team commends the MEDCOM for its implementation of TeamSTEPPS and the T-TPQ. It is this type of well-thought out and carefully planned application of TeamSTEPPS that will continue to move MHS forward and towards becoming a high performing, highly reliable health care system.

Offering various ready-to-use tools, materials and resources, TeamSTEPPS can be tailored to address the specific needs of an organization to seamlessly incorporate its principles into all areas of a health care system. In fact, it is only by fully integrating the tools that TeamSTEPPS offers into our day-to-day activities that Military Health System (MHS) leadership, frontline staff and patient safety professionals will truly benefit from leveraging this methodology. A great example of this is the work and research that the U.S Army Medical Command (MEDCOM) conducted regarding the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ). Highlights of this work were presented at the 2016 National TeamSTEPPS conference this past June.

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MHS Patient Safety Data Snapshot

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7/1/2016

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DoD PSP Learning Update July August 2016

Publication

6/29/2016

The Learning Update delivers an upcoming schedule of DoD PSP and other patient safety activities, tools and resources to help you increase your patient safety knowledge and skills. This edition highlights upcoming patient safety activities July and August 2016.

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