INSIDE: Patient Safety Awards Supplement
WINTER 2008 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
PATIENT SAFETY HIGHLIGHTS FROM MHS CONFERENCE
Awards Presentation, Breakout Sessions Feature Patient Safety Activities
Patient Safety Award Photos
Implementation of System Changes or
Interventions
22nd Medical Group, McConnell AFB, KS
Ruth M. Eckert, Chief, Performance
Improvement, receiving Patient Safety
Award from Dr. Smith, Dr. Jones and Lt
Gen James G. Roudebush, Surgeon Gen-
eral, USAF.
Use of Technology
Madigan AMC, Tacoma, WA
Dr. Smith, Dr. Jones and LTG Eric B.
Schoomaker, Surgeon General, USA pre-
sent Patient Safety Award to MAJ Shad
Deering, Medical Director, Andersen Simu-
lation Center.
Implementation of System Changes or
Interventions
US Naval Hospital Sigonella, Italy
Hospital Commander CAPT Helen V. Pearl-
man, accepts Patient Safety Award from Dr.
Smith, Dr. Jones and VADM Adam M.
Robinson, Jr., Surgeon General, USN.
Use of Technology
49th Medical Group, Holloman AFB, NM
Lt Col Garry Feld receiving Patient Safety
Award from Dr. Smith, Dr. Jones and Lt
Gen James G. Roudebush, Surgeon Gen-
eral, USAF.
Improvements to Team Performance
59th Medical Wing, Wilford Hall MC,
Lackland AFB, TX
Capt Jose L. Sanchez, NC accepts Patient
Safety Award from Dr. Smith, Dr. Jones and
Lt Gen James G. Roudebush, Surgeon
General, USAF.
WINTER 2008
3 2008 Tri-Service Survey Plans
4 PSC Human Factors Corner
T
he 2007 Patient Safety Awards were formally presented at
the Military Health System (MHS) Conference in Wash-
ington, D.C. The Conference, held January 28 through 31
brought together MHS components and partners from around
the world for four days of general sessions with Executive Lead-
ership, targeted breakout sessions, exhibitions and poster presen-
tations. Especially exciting this year was a plenary session titled
Grand Rounds From the Front Line which linked commanders
from remote, deployed locations in a virtual panel discussion of
their challenges and successes, and a special screening of Fighting
For Life, a new film interweaving stories of military doctors, nurs-
es and medics and the wounded warriors they serve, (see
www.fightingforlifethemovie.com for nation-wide screen dates
and locations.)
The traditional awards ceremony, held on Wednesday morning,
featured Dr. Stephen L. Jones, DHA, Principal Deputy Assistant
Secretary of Defense (Health Affairs), Dr. Jack Smith, Acting
Deputy Assistant Secretary of Defense for Clinical and Program
Policy and Acting Chief Medical Officer for TRICARE Manage-
ment Activitiy, and each service Surgeon General presenting the
2007 Patient Safety Awards to representatives of the recognized
facility. Pictured at left are the official photos of the awards
presentation, courtesy of Austin Camacho, Deputy Director,
Public Affairs Office, TRICARE Management Activity.
While the Patient Safety Awards presentation was the most dra-
matic recognition of the importance of safety-related activities
throughout the MHS, patient safety efforts had a visible pres-
ence in all of the various Conference venues.
Several breakout sessions featured patient safety initiatives, many
of which have been publicized in the Patient Safety Newsletter
over the past year. The Patient Safety Awards breakout session
provided a well-attended forum for presentation and discussion
of the five award-winning initiatives. Dr. Jack Smith, Acting
5 Patient Safety Album
PATIENT SAFETY CON-
FERENCE HIGHLIGHTS
Continued from Page 1
Deputy Assistant Secretary of Defense for
Clinical and Program Policy and Acting
Chief Medical Officer for TRICARE Man-
agement Activity attended the breakout ses-
sion. Dr. Smith congratulated all the presen-
ters and the facilities they represented, and
presented each with a commemorative coin
from the Office of the Chief Medical Officer
in recognition of their outstanding contribu-
tions to patient safety. Below is a list of the
patient safety-related breakout sessions:
Innovations In Patient Safety: 2008 Department
of Defense Patient Safety Awards (COL Steven
Grimes, AN, USA and award recipients)
The Clinical Microsystem Framework: Its
Impact on Process Improvement, with Practi-
cal and Measurable Change (Eric S. Marks,
MD; Diana Luan, PhD, MPA, MS)
Developing A Rapid Response Team: A Focus
on Patient Care (LTC Eric Crawley, MC, USA)
TeamSTEPPS — Training Applications for
Emergency Obstetrics and Forward Operating
Surgical Team (LTC Donald W. Robinson,
MC, USA; MAJ Shad Deering, MC, USA)
TeamSTEPPS Training — Parts I and II
(COL Sherry Ferguson, AN, USA; Dr. Tim
McGuirk; Ms. Heidi B. King, MS, CHE)
Potential Use in the Military Health System —
National Healthcare Safety Network (NHSN)
(CAPT Teresa C. Horan MPH, USPHS, CDC)
Access www.health.mil to see breakout ses-
sions on-line.
The Poster Exhibit included, as two of its six
categories, Quality and Effective Patient
Partnerships, both of which enhance the
overall safety of patients. Winning the cate-
gory of Patient Partnerships was a poster
submitted by Ms. Nancy Radebaugh of
Darnall Army Medical Center, entitled
“Ambulatory Medication Reconciliation: A
Prescription for Partnership”. The poster
depicted the success of the wallet card writ-
ten medication list patients carry at Dar-
nall. The card is reviewed and updated at all
medical encounters, and its use ensures
communication of all therapies to the
patient care team.
The DoD Patient Safety Program (PSP) and
the Healthcare Team Coordination Program
(HCTCP) displayed their booths in the Exhi-
bition Hall. New this year was the Dental
Patient Safety Booth, a US Army Dental
Command initiative featured in the Fall 2007

CDR Tanya Ponder, NC, USN explains the Clinical Microsystems initia-
tive submitted by US Naval Hospital, Sigonella at the Patient Safety
Awards breakout session, MHS Conference.

Award winning poster, submitted by Ms. Nancy Radebaugh, depicting

the Medication Reconciliation initiative at Darnall AMC, Ft. Hood, TX.

Presenters of the Patient Safety Awards initiatives pose following the

MHS Conference breakout session with COL Steven Grimes, Director,
DoD Patient Safety Program and Dr. Jack Smith, Acting Deputy Assis-
tant Secretary of Defense for Clinical and Program Policy and Acting
Chief Medical Officer for TRICARE Management Activity. Pictured from
left to right are: CAPT Jennifer Baker, Chief of Pharmacy, 49th Medical
Group, Holloman AFB, NM; COL Grimes; Capt Jose L. Sanchez, NC,
USAF, 59th Medical Wing, Wilford Hall MC, Lackland AFB, TX; Dr.
Smith; Ruth Eckert, Chief, Performance Improvement, 22nd Medical DoD Patient Safety Program and HCTCP booths. Pictured are Diana
Group, McConnell AFB, KS; MAJ Shad Derring, MC, USA, Medical Luan, PhD, RN, MPA, MS, Sr Research Policy Specialist CERPS and Paul
Director, Andersen Simulation Center, Madigan AMC, Tacoma, WA. Hoerner, Lt Col USAF, BSC, Deputy Director, DoD Patient Safety Center.

2 WINTER 2008 PATIENT SAFETY

DoD 2008 TRI-SERVICE SURVEY ON PATIENT SAFETY
Spring Rollout Planned for Web-based Assessment Tool

P
lans for the deployment of the 2008
DoD Tri-Service Survey on Patient
Safety are underway. In 2005/2006,
DoD deployed the first round of the survey
to assess the culture of patient safety within
Military Health System (MHS) facilities.
Until that time, limited tools to assess patient
safety culture had been available to DoD.
The DoD Tri-Service Survey on Patient Safe-
ty, sponsored and funded by TRICARE Man-
agement Activity (TMA), is a web survey
designed to assess staff opinions about issues
related to patient safety, medical errors, and
event reporting in the MHS. All staff working
in Army, Navy, and Air Force Military Treat-
ment Facilities (MTFs) and dental treatment
facilities worldwide will be asked to complete
this survey. Rollout is scheduled for March
2008 with results available in September 2008.
The survey assesses the following areas of
patient safety in Military Health System
facilities:
• Overall perceptions of patient safety
• Frequency of reporting events
• Management support for patient safety
• Supervisor/manager expectations &
actions promoting patient safety
• Organizational learning/continuous
improvement
• Teamwork within work areas
• Teamwork across work areas
• Communication openness
• Feedback/communication about error
• Nonpunitive response to error
• Staffing issues
• Issues related to handoffs & transitions
Group survey results will be reported at the
facility and Service levels, as well as the MHS
overall. Feedback comparing trends between
the 2005/2006 and 2008 survey results will be
provided. Strengths and areas for improve-
ment will be identified. The results will help
the DoD assess the status of patient safety
improvement efforts within MHS facilities,
raise staff awareness about patient safety, and
meet requirements of the Joint Commission.
Results from the 2005/2006 survey were used
throughout the MHS to help develop next
step strategies to improve patient safety.
Overall, 53% of all MHS staff (62,548
respondents) completed the 2005/2006 sur-
vey. Most respondents (80%) gave their work
area either an “A -Excellent” or a “B -Very
Good” patient safety grade. Nine of the 12
survey areas received a 50% or better positive
response; only 3 areas fell below 50%.
Teamwork Within Work Areas, Supervisor/
Manager Expectations and Actions Promoting
Patient Safety, and Management Support for
Patient Safety were considered strengths.
Areas for improvement included Handoffs
and Transitions, Staffing, Nonpunitive
Response to Error, and Number of Events
Reported. Detailed results from the 2005/
2006 survey were published in the Summer
2006 issue of the Patient Safety Program
Newsletter.
The success of the upcoming March 2008
survey depends on the participation of all
MHS staff. Please contribute to the results by
participating in the survey. For any questions
or comments, please contact Mr. Michael
Datena (RPh), DoD Patient Safety Program,
at michael.datena@tma.osd.mil.

"The DoD Patient Safety Program is dedicated to improving patient safety

across the Military Health System (MHS). After the 2001 official launch of the
DoD Patient Safety Program, the 2005 survey provided a first-time assessment
of the safety culture within the MHS.

We aim to learn from the 2005 and 2008 survey results, making comparisons
where appropriate, to enable open discussions regarding the culture of safety in
our system and how we can continuously work together to further improve it."

—Jack Smith, MD, MMM

Acting Deputy Assistant Secretary of Defense for Clinical and Program Policy
United States Department of Defense Military Health System
January 2008

PATIENT SAFETY WINTER 2008 3

 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting

THE HUMAN
FACTORS CORNER FMEA TOPIC GENERATORS
Narrowing Your FMEA Scope
Erin Lawler, MS Within Your Facility
• Introduction of a new process or product

H
ave you ever needed to complete a
FMEA, but have felt overwhelmed
choosing a topic? You are not alone.
FMEAs can be overwhelming, but there are
useful tips that can help focus your FMEA
process, narrow the scope, and make the
FMEA a manageable undertaking.
Since 1 July 2001, the Joint Commission has
required accredited institutions to perform
at least one proactive risk analysis on a high
risk process within a facility.1,2 As opposed to
reactive analytical methods that respond to
an adverse event once it has occurred,
prospective analyses are systematic methods
that anticipate, identify, and respond to ways
in which a process or product could fail.
Through redesigning and mistake-proofing
critical processes, potential risks and unsafe
variances are eliminated or mitigated before
they lead to an adverse event.
• Changes to the design of a product, process, environment, workflow, etc
• Changes to the relationship of one process component/step to other components
• Initiation of new policies, procedures, regulations
• Staff/patient feedback
• Internal data tracking and near miss reports within facility
Patient Safety Center
• Root cause and FMEA information provided in Patient Safety Center Quarterly and
Annual Reports
• Monthly Summary Reports
• Safety Alerts
National/International Resources
• Error-prone processes indicated in literature
• National Patient Safety Goals and root causes reported by the Joint Commission
• Sentinel Event Alerts (www.jcaho.org)
• Institute for Healthcare Improvement (IHI), Institute for Safe Medication Practices (ISMP),
National Patient Safety Foundation (NPSF) and other professional organizations
(Information sources 1,4)

Failure Modes and Effects Analysis (FMEA)

satisfies the Joint Commission requirement
and is the most common prospective risk
analysis method used within the MHS. It
can be argued that “if FMEA could do
exactly what it is claimed to be, there would
be no need for RCA”.3 However, FMEAs are
not simple, effortless processes. They can
be time-consuming and unwieldy without
proper direction. It is important to define
the process, purpose and goals for complet-
ing the FMEA early in order to efficiently
manage time and resources. Identifying an
appropriate high risk process and control-
ling the scope of the FMEA is paramount.
How to Choose a High-Risk Process
Due to their complexity, high risk process-
es have a higher chance for adverse patient
safety outcomes if a process or product fail-
ure occurs3. Healthcare facilities often have
many high-risk processes to choose from
and the most critical process may be incon-
spicuous against equally error-ridden or
high risk candidates.
Honing in on a FMEA topic can be guided
by considering the following questions
generated by the Joint Commission1:
“Which process is most likely to affect the
safety of patients served?”
“Which process has the highest potential
volume and, thus, the greatest likelihood
for safety ramifications?”
“Which process is most interrelated to
other health care processes and, thus, if
problematic, is most likely to affect mul-
tiple processes?”
High risk processes can differ among facil-
ities. Look within your own facility to see
what processes are critical and relevant to
the facility. The box above outlines helpful
resources in identifying high risk processes.
FMEA teams can spend a great deal of time
and angst trying to find the absolute, most
critical high-risk process to review. If you
are having difficulty identifying a standout
high-risk process to consider, keep in mind
that most high-risk processes would bene-
fit from a FMEA review, and other high-
risk processes and sub-processes can be
slated for review in future years.
How to Narrow the Scope
Once a high-risk process has been selected,
there is a natural tendency to want to eval-
uate and “fix” the entire process at once.
High-risk processes are highly complex. It
is often too overwhelming and time-con-
suming to consider each component.
FMEA teams can experience burn-out,
become lost in the process, or produce an
ineffective and incomplete FMEA. Identify-
ing and evaluating one component of the
process that is deemed most error-prone is
Article continued on page 6

4 WINTER 2008 PATIENT SAFETY

 PATIENT SAFETY IN ACTION
Experiences and Suggestions From the Field

PATIENT SAFETY PHOTO ALBUM

Patient Safety: All Day, Every Day Across the MHS

T
he photos and images below are the first in what is intended as a regular feature of the Patient Safety Newsletter. We recognize that
providers across the Military Health System (MHS) are working day in and day out, in ways large and small, to improve and sustain
patient safety. While not every effort rises to the level of an initiative, innovation or program, every effort makes our patients safer
and makes medical care across the MHS more valuable. We want to capture and publish these safety moments as a way of sharing the many
MHS successes and as a way of saying thank you to our dedicated caregivers.

3rd MDG, Elmendorf AFB, Alaska

Patient Safety Manager Carole Durant YOU ought to be in pictures! Send your
sends this photo with word that during patient safety snapshot to: poetgen@aol.com
2008 the 3 MDG will focus on Team- or to your service patient safety representative
STEPPS briefs, debriefs and team huddles
throughout the facility. Pictured conduct- for publication in the Spring Newsletter.
ing a morning Brief are Multi-Service
Unit staff members A1C Bowling, Lt Mor-
ris, Lt Dunlevy and Capt Walking Eagle.

PATIENT SAFETY WEEK REMINDER

AMC TeamSTEPPS Activities
From Lynette M. Bell, RN, Lt Col (Ret),
HQ/SGOQ, Scott AFB, Il comes this
photo montage picturing AMC ambula-
tory clinics performing TeamSTEPPS brief-
ings, debriefings and huddles. Pictured
are: 436 MDG Pharmacy Dover AFB; 43
MDG Flight Medicine Clinic Pope AFB;
437 MDG Family Practice Charleston
AFB; 375 MDG Flight Medicine Clinic
Scott AFB; and 60 MDG Patient Simula-
tion Center Travis AFB.
35th MDG, Misawa AFB, Japan
The Rapid Response guerney developed
by the 35 MDG as part of their IHI initia-
tive is pictured here. Patient Safety Man-
ager Paul Sayles explains that the Rapid
Response team answers all calls with this
fully equipped guerney, which makes
patient transfers, when they are neces-
sary, more timely and more easily coordi-
nated.
20 MDG, Shaw AFB, South Carolina
Patient Safety Group at Shaw AFB are
pictured as they gather to work on
improving the medication reconciliation
and check-out processes. Pictured, left
to right are: back row, Lt Col Busch, SSgt
McLivain, MSgt Belen, Capt Marshall;
front row, Mrs. Holder, Mrs. Murray, TSgt
Shingleton, SSgt Clemens. Photo courtesy
of Shaw Patient Safety Manager Robin
Shingleton, TSgt, USAF.
The National Patient Safety Foundation is
sponsoring its annual National Patient
Safety Awareness Week March 2 to March
8, 2008. This national education and
awareness-building campaign is meant to
highlight efforts to improve patient safety
on the local level. Hospitals and health
care organizations nationwide are urged to
plan events to promote patient safety with-
in their organizations. A focus on educat-
ing patients to become involved with their
own health care, as well as building part-
nerships between hospitals and their
patient communities is encouraged.
As in past years, the DoD Patient Safety
Program enthusiastically supports National
Patient Safety Awareness Week. Last year
military treatment facilities (MTFs) across
the Military Health System celebrated the
week’s theme with creative activities that
included patient safety-related games,
poster displays, demonstrations and social
events for staff and patients alike. (See
Spring 2007 issue DoD Patient Safety
Newsletter for photos and descriptions) As
MTFs hold activities to celebrate this year’s
theme, which again is entitled “A Road
Taken Together”, we encourage you to take
photos. Please send them, along with a
description of your events, to the Newslet-
ter (poetgen@aol.com) for publication in
our next issue.

PATIENT SAFETY WINTER 2008 5

THE HUMAN
FACTORS CORNER
Continued from Page 4
Tip 1: Flowchart your high-risk process. (This is a partial illustration for display purposes)
Establish Prescribe Process
plan of Medica- order
care tion/Order
Lab Tests
Tip 2: If the process
has many steps or if each
process step has many
sub-steps, consider which
step has the most known
weaknesses, greatest risk
for error, and greatest
impact on patient safety.
This will help you identify
which process step to
further evaluate
Evaluate safety/
appropriateness
Tip 4: Proceed with FMEA process of determining failure modes, causes, etc for each
sub process step
This Anticoagulant FMEA example illustrates tips for narrowing the scope to one process compo-
nent or step if the process is too complex. Information from ISMP Anticoagulant FMEA, ismp.org.
recommended. Other components of the
process can be resumed and reviewed in
future FMEA efforts, and it would be
important to do so.
Following these FMEA tips in the illustra-
tion above will help you keep the FMEA
process a manageable, efficient and effective
tool for improving healthcare processes in
your facility. The Center for Research and
Education in Patient Safety (CERPS) offers
a half-day course on conducting FMEAs
(http://dodpatientsafety.usuhs.mil.) For
more information on FMEAs , please con-
tact Erin Lawler (lawlerl@afip.osd.mil;
301-295-8125.)
6 WINTER 2008 PATIENT SAFETY
PATIENT SAFETY
PROGRAM WEBSITE
http://dodpatientsafety.usuhs.mil
The DoD Patient Safety Program website is a
timely source of information for all health-
care providers across the Military Health
System. You are encouraged to access the
website, which is frequently updated, to keep
Prepare Administer Monitor Patient Discharge abreast of developments within the DoD
order/ drug education/
Dispense Self admin- Patient Safety Program. On the website you
istration will find a "What's New" section and a
"What's New Archive" link.
Easy access to the current Patient Safety
Send Newsletter, as well as the newsletter archive,
}
order to
is contained on the website. Related to this
pharmacy
Winter 2008 issue, you will find past Patient
Safety Award articles dating from the first
Tip 3: Flowchart the sub-steps or award presentation in January, 2004. In
sub-processes of that process step
back issues, you can also read more about
Enter into
TeamSTEPPS (Spring and Fall 2006, Sum-
computer
mer 2007); Rapid Response Teams (Spring
2007) and the Tri-Service Survey Results
(Summer 2006).
of order
PATIENT SAFETY
(Cont.) PROGRAM NEWSLETTER
Published quarterly by the Department of Defense
(DoD) Patient Safety Center to highlight the progress
of the DoD Patient Safety Program.
DoD Patient Safety Program
Office of the Assistant Secretary
of Defense (Health Affairs)
TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike
Falls Church, Virginia 22041
1) The Joint Commission on Accreditation of 703-681-0064
Forward comments and suggestions to:
Healthcare Organizations. (2005). Failure DoD Patient Safety Center
Modes and Effects Analysis in Health Care: Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100
Proactive Risk Reduction (2nd ed). Joint Silver Spring, Maryland 20910
Commission Resources. Phone: 301-295-7242
Toll free: 1-800-863-3263
2) Rich, D.S. (2001). Complying with the DSN: 295-7242 • Fax: 301-295-7217
E-Mail: patientsafety@afip.osd.mil
FMEA Requirements of the New Patient Safe- Website: http://dodpatientsafety.usuhs.mil
ty Standards. The Joint Commission on E-Mail to editor: poetgen@aol.com
Accreditation of Healthcare Organizations. DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM
3) Senders, J.W. (2004). FMEA and RCA: COL Steve Grimes
the mantras of modern risk management. DIRECTOR, PATIENT SAFETY CENTER
Geoffrey Rake, MD
Qual Saf Health Care, 13, 249-250.
DIRECTOR, CENTER FOR EDUCATION
4) The Joint Commission on Accreditation of AND RESEARCH IN PATIENT SAFETY
Eric S. Marks, MD
Healthcare Organizations. (2005). Systems
DIRECTOR, HEALTHCARE TEAM
analysis: prioritizing processes for FMEA. COORDINATION PROGRAM
Ms. Heidi King
Joint Commission Perspectives on Patient
SERVICE REPRESENTATIVES
Safety, 5(5). Joint Commission Resources. ARMY
LTC Robert Durkee
NAVY
Ms. Carmen Birk
AIR FORCE
Ms. Susan Brockman
PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
Phyllis M. Oetgen, JD, MSW