NEXT ISSUE: Results of DoD Patient Safety Culture Survey; Over 62,000 Responses Received

SPRING 2006 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

TeamSTEPPS PART OF DoD TRAINING FOR

IMPROVED PATIENT SAFETY
I
f you are involved in the DoD Patient training and process improvement, an inte- quality and safety in healthcare developed by
Safety Program, you probably have grated effort in the service of providing a the DoD Patient Safety Program in collabora-
attended one of the multi-day training safer experience for our patients. tion with the Agency for Healthcare Research
sessions offered by the Center for Education and Quality (AHRQ). It is comprised of spe-
and Research in Patient Safety (CERPS). TeamSTEPPS…. cific key elements that include pre-training
Begun soon after the Patient Safety Program Team Strategies and Tools to Enhance assessment and preparation, training of
was formally organized in 2001, these didac- Performance and Patient Safety selected instructors, and a customizable plan
tic experiences have evolved to include sepa- for implementation and sustainment of
rate modules for introductory patient safety TeamSTEPPS is the comprehensive team- teamwork performance across a department
concepts and advanced training for patient work training system designed to improve Continued on Page 2
safety managers. Among the many topics
covered, the latest information on reporting
to the Patient Safety Center is included, as is
an introduction to TeamSTEPPS, the evi-
dence-based teamwork training system Key Elements and Available Tools
developed by the Health Care Team Coordi-
nation Program (HCTCP), a part of the DoD Planning, Training
Patient Safety Program. For more informa- Assessment & Implementation Sustainment
tion on all the curricula offered by the Patient • Initial site assessment • Train-the-Trainer • Monitor Plan
Safety Program, or to review extensive • Leadership support – Fundamentals Course • Ongoing Leadership
• Observations – Change Management involvement
patient safety resources and helpful tools, • Culture Survey – Coaching Workshop – Executive sponsor
access the CERPS website at: • Create a Change Team – Implementation updates
www.usuhs.mil/cerps/index.shtml. • Select Instructor Cadre Workshop • Continued Training
• Select Executive Sponsor – Practice Teaching – New staff
The integration of education, teamwork, • Establishment of goals/ Session – Refresher
reporting, and reviewing and implementing metrics – Train-the-Participant – In-service
best practices is an important goal of the • SWOT analysis • Essentials Course • Newcomers’ Orientation
• Plan training • On-site support of • Coach
DoD Patient Safety Program. In this Spring • Grand rounds initial training • Integration of team tools
issue of the Newsletter, we focus on two (multidisciplinary) • Development of Team • Team Performance
aspects of training – TeamSTEPPS and the • Communication Improvement Action Plan Observations
campaign • Test Intervention • Post-training assessment
training Military Treatment Facilities per- • Pre-training (baseline) • Track Aims • Metric results–reporting,
form daily, as reported to the Patient Safety survey • Communicate Updates analysis/reinforce
Center. One is a formal learning experience, • Set Aims • Web-based updates
• Continuous Improvement
the other a practical response to perceived or
potential safety concerns amongst caregivers.
Both, however, are pieces of the larger whole TeamSTEPPS Key Elements and Available Tools at a glance. From the TeamSTEPPS
– the DoD Patient Safety Program’s cycle of Course Management Guide, TeamSTEPPS 06.1.

SPRING 2006

3 PSC: Training Is
First Response 4 Publication Renamed
“Focused Review” 5 Patient-Centered Aids
6 Patient Safety
Hits the News!
TeamSTEPPS Training attitudes. Perhaps the most well-known exam- Delivery, Operating Room, Intensive Care
Continued from Page 1 ple of an effective teamwork strategy for reduc- Unit, Combat Medicine and “whole hospital”
or facility. Within the last eighteen months, the ing errors is Crew Resource Management applications. TeamSTEPPS was developed to
DoD has established seven hundred (700) (CRM), the system adopted by the aviation provide a comprehensive unified curriculum,
trainers/coaches of teamwork principles in industry. Mandated by the Federal Aviation based on more than twenty years of research
over thirty (30) Military Treatment Facilities Administration since 1979, CRM emphasizes on teams and team performance, for use
(MTFs). These instructors have initiated train- the role of human factors in high-stress, high- among all three Services.
ing at various levels to thousands of Military risk environments, and implements intense, TeamSTEPPS provides an approach to
Health System healthcare professionals. As focused communication, teamwork training teamwork training that imparts specific teach-
well, teamwork competencies have been inte- and operations designed to increase safety. The able-learnable skills supporting team per-
grated into the program of instruction for pre- rate of U.S. airline fatalities has steadily declined formance principles to include training
deployment training for forward surgical since the adoption of CRM; from 2001 through requirements, behavioral methods, human
teams as they prepare for battlefield healthcare. Dec. 2005 there were no fatalities. factors and cultural change designed to
While not always part of the health care lex- Within the Department of Defense, med- improve quality and patient safety. This initia-
icon, teamwork principles have become ical team training was mandated in the tive is available to all MTFs. It is a stand-alone
increasingly recognized as integral to the effort National Defense Authorization Act of 2001. curriculum, with multiple modules, designed
to create a culture of safety in medicine. The This Act, which followed the Institute of Med- to be implemented after a well-thought out
connection between improved teamwork and icine report on medical errors, established the plan over a timeline of five to nine months for
fewer errors may seem intuitive, but healthcare Patient Safety Program, and tasked the full implementation (varying with the size of
has traditionally been practiced as individual Healthcare Team Coordination Program with the unit(s) trained). A critical threshold issue
silos rather than as a team endeavor. Other pro- integrating medical team training throughout for MTFs considering TeamSTEPPS training
fessions, however, have historically recognized all healthcare operations. A multi-facility is their commitment to the process, as meas-
the importance of teams and team perform- research project for Emergency Departments ured by the requirement of leadership buy-in.
ance. Research accumulated over the past sever- that introduced teamwork training based on The success of this teamwork initiative
al decades in diverse areas such as aviation, CRM captured notable decreases in observed depends on strong leadership to communi-
nuclear power, military operations and indus- errors and a subsequent increase in patient cate the vision, establish goal-oriented met-
trial practice has provided a science of team- and staff satisfaction. Positive outcomes rics, and assign an executive sponsor and a
work – an evidence-based set of core compe- resulted in the expansion of medical team change team. With the support of leadership,
tencies with identified knowledge, skills and training to the specialty areas of Labor and the change team (along with staff at the sharp
end of care) develops a
Team Improvement
Action Plan which
includes training and
implementation , and
measures which are mon-
itored over time. Coach-
ing and mentoring on the
unit or in the clinic have
been identified as the key
critical success factors.
Actual TeamSTEPPS
training includes an ini-
tial pre-training assess-
ment of the MTF’s readi-
ness, a training roll-out
strategy — in most cases
using a train-the-trainer
model — and continued
follow-up and feedback
through consultation and
participation in the
Learning Action Network
(LAN). The bi-monthly
LAN is designed to create
opportunities to share les-
sons learned and best
practices by networking
via telephone with other
TeamSTEPPS “Shift Toward A Culture of Safety”. From the TeamSTEPPS Implementation Presentation. Continued on Page 5

2 SPRING 2006 PATIENT SAFETY

 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting
occur. This is especially true when codes are devices, so time is not wasted when a code is
TRAINING IS PART OF called in areas that have infrequent code called in these less anticipated areas.
CULTURE OF SAFETY events, such as the labor and delivery room.
AMONG MTFs In these instances, staff may have difficulty Equipment Utilization
even locating the necessary equipment or
Reports List Training As First medication, and they may not know who is

E
quipment becomes a problem when staff
Response To Adverse Events on call or how to contact them. Other code- is unfamiliar with the equipment’s func-
related difficulties run a wide gamut: on-call tion, appearance, or proper utilization.
Mary Ann Davis, RN, BSN, MSA residents unfamiliar with treatment for a Hospital and clinic staffs alike encounter a host
Nurse Risk Manager, Patient Safety Center particular patient; newly-assigned nurses of equipment in their practice each day. They

T
he Patient Safety Center (PSC) uses who lack adequate orientation; lack of a des- need to be familiar with each instrument or
the data derived from the Monthly ignated code leader; physicians who are hard machine as a working whole, as well as the dif-
Summary Reports (MSRs) to provide to locate because the mode of communica- ferent parts of each machine. This is no small
lessons learned and training suggestions to tion is not dependable; overhead announce- challenge in our technologically complex
healthcare providers. Information included ment systems too low to be heard; crash carts health care system.
in the MSRs reflects the importance of train- that are hard to locate or inadequately Safety issues based on problems with
ing on the Military Treatment Facility (MTF) stocked. equipment can be simple or complex, but,
level, as well. Staff is proactive in responding Since a code event is precipitated by a res- whatever their origin, they have the potential to
to perceived problems. They provide training piratory or cardiac arrest, the response must cause harm and even death. It is easy to mistake
within their facilities, and their experiences to be timely. MOCK CODES are the training one instrument for another when they look
contribute to the general patient safety technique of choice. They address both prac- alike. This is more likely when similar pieces of
knowledge-base. This month, the PSC shares tice and equipment deficiencies. Your reports equipment are stored together, as they fre-
training lessons derived from your action tell us they are now being performed at regu- quently are. Some equipment, by its nature,
plans. lar and frequent intervals in many MTFs -- at presents multiple opportunities for human
The PSC receives monthly incident least once a quarter, and on a rotational basis error. The fetal monitor is a good example of
reports and JCAHO reportable Root Cause in low-density patient areas where a code is such a device. If the fetal monitor is incorrect-
Analyses (RCAs) from MTFs all over the unlikely. Although some training related to a ly connected, it may record the mother’s heart
world. Four years ago, when the PSC first code event is classroom-based, drills are the rate, rather than that of the fetus. There is also
began to receive incident reports, the fore- key to keep staff prepared and equipment the potential to misplace the monitor’s elec-
most reaction to adverse events was to edu- ready. During a mock code, equipment can trode; the alarm may be disconnected either
cate and train the staff. This action still takes be examined, replaced, ordered or repaired, accidentally or on purpose; the fetal monitor
precedence today. The type of training varies eliminating the risk of equipment absence or strip may be incorrectly read; and finally, the
– from unit-specific exercises to departmen- failure in an actual emergency. monitor itself may not be checked often
tal reviews all the way to patient safety stand- Among the specific code training proce- enough to ensure proper functioning. Lack of
downs, which encompass an entire facility. dures reported to the PSC, the following are familiarity with equipment can also contribute
Whatever the mode or scope, staff education directly responsive to problems encountered. to an event. New or revised equipment usually
and training is universal among our MTFs. It To maintain provider competence, residents includes improved but often repositioned
is the immediate and preferred action-step and nursing staff are being trained in neona- switches, alarms, connections or ports. If the
when a patient safety issue arises. tal, pediatric and adult resuscitation, as well device is used without first reading the manual
There are two areas that lately stand out as team communication. Code team mem- or receiving instructions, the equipment may
in the MSRs as targets for increased staff bers and patient care personnel are required not function or may function incorrectly.
attention. Code blue procedures and equip- to participate in two mock codes annually, When dealing with equipment, MTFs
ment utilization/familiarization particularly and MTFs are adding code policies to the report “JUST-IN-TIME” training as their pre-
benefit from on-going, on-site training employee orientation check-list. Rapid code ferred action-step. However, to be effective,
efforts. Your reports suggest that, in these two response is being addressed in a number of “just-in-time” training needs to be fully respon-
instances, fairly simple techniques, if they are ways. One MTF has placed a chart naming sive to each element of equipment utilization.
consistent and comprehensive, reap large the designated code responders at the duty Staff is usually told how equipment works, but
patient safety rewards. desk, ensuring universal accessibility (espe- is not always fully versed on why it is used, what
cially for the weekend and night shifts) and happens if it fails, and when to report a prob-
Code Blue Procedures timely notification. Several facilities are lem. “Just-in-time” training should be drilled
using cell phones within the hospital for down in settings all around the hospital to

R
eports to the PSC show that delays and code contact. Code carts have been stocked include the following next level safeguards.
confusion when initiating codes or with standardized code equipment, includ- Operating room staff, besides being familiar
during the code procedure sometimes ing neonatal and pediatric resuscitation Continued on Page 4

PATIENT SAFETY SPRING 2006 3

 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting
Culture of Safety
Continued from Page 3 PSC CHANGES NAME OF PUBLICATION
“Patient Safety Advisory” Now Called “FOCUSED REVIEW”
with every piece of equipment and instrument,
should physically check each piece as it is called The Patient Safety Center has offs, education and training, side-chair
out for surgery. Obstetric staff, including nurs- changed the name of its bi-monthly dental surgery. At that time, the first
es and physicians, should be trained on all publication from “Patient Safety Advi- issue of the publication, focusing on
aspects of fetal monitors. Frequent ambulance sory” to “Focused Review”. unintentional retained foreign bodies,
drills should be held to ensure familiarization was outlined. Since the Winter newslet-
with the often replaced and/or updated trans- Because the publication is meant to ter, a second publication has been dis-
port process and equipment. focus attention on particular issues, tributed, highlighting issues related to
Whatever the issue, training will continue and provide comprehensive informa- eye surgery.
to be a preferred corrective action in our tion to MHS facilities, including back-
MTFs. It will vary among facilities, and will ground behind the issues, practice The third issue of “Focused Review”
reflect the culture of each Service and site. guidance related to the issues, and sug- will be published this summer. It will
Yet, certain universal elements transcend gested actions to prevent or mitigate focus on education and training. All
localities. The PSC suggests that all training identified health risks arising from issues of “Focused Review” will be made
efforts should include the following core ele- these issues, the new publication is available on the secured DoD Patient
ments: they should be coordinated, frequent, more a focused review than an acute Safety Program website, or can be
consistent and comprehensive; they should advisory. Thus, the new name more obtained from your Service representa-
include drills and onsite instruction; they accurately reflects both the content and tive. Feedback on the topics selected, or
should drill down to address the universe of intent of this print effort. comments and suggestions from the
problems associated with technologically field on future topics relevant to your
complex equipment. To ensure that training In the Winter issue of the Newslet- needs, can be forwarded to the Patient
in whatever area is effective, validation ter, this new publication was intro- Safety Center. Phone contact is: 301-
should be part of all training exercises. MTFs duced and explained. The article out- 295-8117; via email at:
should perform post-training tests, audits, lined areas that will be featured in [email protected].
and spot checks to measure staff compliance future publications, including hand-
and competency, and to assess the effective-
ness of their training.

PSC “TAKE-HOME” “Take-Homes” for PSOs

REMINDERS DATA COLLECTION • Take notes in team
meetings and then
should consist of:
Training At a Glance  Know and use your afterwards use software
• Coversheet
MTF’s data: • Process Flowchart
to enter notes until fully
• Key for determining MTF’s comfortable • Risk Assessment

T
he Patient Safety Center (PSC) risks and setting priorities  Use standard DoD RCA
provides a segment of formal Report format for the • Failure Modes
• Watch for unusual
training to Patient Safety Officers patterns package submitted to the • Effects (of Failure
Patient Safety Center Modes)
(PSOs) during the Patient Safety Train-  Don’t only focus on the
ing sessions. A full review of patient big rocks (JCAHO NPSGs  Use the RCA feedback to • Causes (of Failure
or Sentinel Events); watch improve your RCAs Modes)
safety reporting issues is presented. To for near-misses or  Debrief your RCA teams, • Hazard Scores (Severity,
the right are a few key points from the frequent event sources look at team products: Probability, &
PSC presentation. These are the essen- for improvements Detectability)
• If not successful, explore
tial elements of reporting which should  Watch for hang-ups causes • Action Plan
in incident report flow • Analyze your RCA
serve as a thumb-nail guide as you col- • Look at your past
 Ask “What are we process FMEAs
lect data and prepare your Monthly
missing?”  Forward the JCAHO
Summary Reports, Root Cause Analyses • Analyze your FMEA
ROOT CAUSE ANALYSES (RCA) follow-up report to the process
and Failure Mode Effects Analyses. Patient Safety Center
These take-home lessons provide you  Understand and use • Learn from FMEA team
TapRooT: FAILURE MODE AND feedback
with a brief “training-at-a-glance” EFFECTS ANALYSES (FMEA)
• Practice using TapRooT
refresher. tools and software  Documented elements

4 SPRING 2006 PATIENT SAFETY

 PATIENT SAFETY IN ACTION
Experiences and Suggestions From the Field

PATIENT-CENTERED AIDS IMPROVE SAFETY

TRICARE, JCAHO Offer Within the purview of DoD patient safety mil/News/?id=63AAB03F63464C0F86C7243D
efforts, TRICARE Management Activity has E7BFBE21
Helpful Resources developed a pair of patient-centered Recognizing that patients are becoming

O
ne important component of patient brochures entitled “ASK ME”. These compan- increasingly involved in their health-care
safety is an informed, engaged and ion pieces outline five steps to safer health decisions, Joint Commission Resources (JCR)
proactive patient. The more the care, one directed to patients and the other to has published a guide to help people find reli-
patient knows about his or her own health physicians. TRICARE created these health aids able, trusted sources of health care informa-
issues and medication needs, the more likely to provide patients with specific actions they tion on the Internet. “Patient 101: How to Find
the patient is to recognize situations that pres- can take to be more responsible for their own Reliable Health Information” can be down-
ent the potential for error. Informed patients health care. Patients are directed to speak up loaded from the Joint Commission website. It
play an integral role in assuring a culture of with questions or concerns; keep a list of all is an easy to read fourteen page brochure
safety in health care. JCAHO Patient Safety medications; get the results of any test proce- which includes details on web sites that pro-
Goal 13 specifically encourages the active dure; talk about options if they need hospital vide clinically proven, unbiased and reliable
involvement of patients and their families in a care; and understand what will happen if sur- health care information; explanations and
patient’s care as a patient safety strategy. gery is needed. Physicians are encouraged to background on each website; useful net surf-
Patients are also included in the implementa- review the five steps at every office visit to ing strategies for finding health information;
tion plans for goals relating to improving demonstrate commitment to their patients’ and specific health care topics from dozens of
patient identification; avoiding wrong site sur- safety. Another TRICARE patient aid, “My trusted information sources. This resource is a
gery; reconciling medications; and avoiding Medicines”, offers patients tips on safe medica- welcome assist for physicians and patients
falls. The following resources are simple aids tion management, as well as a place to list alike. Physicians can refer patients to a source
that you might consider using and referencing medications, dosage, directions for use, and that offers accurate information; patients can
in your MTFs, as you encourage your patients purpose of medication. To order these access medical guidance they can trust.
to partner with you in establishing a culture of resources for use with your patients, contact “Patient 101” is available on the redesigned
safety. h t t p s : / / p a t i e n t s a f e t y. s a t x . d i s a . Joint Commission website at: www.jcaho.org.

TeamSTEPPS Training is designed for direct patient caregivers, and error; improved patient and staff satisfac-
Continued from Page 2 includes a four to six hour block of Team- tion; effective communication and informa-
MTFs. Ms. Heidi King, the HCTCP Program STEPPS fundamentals and practice. An tion transfer techniques and optimal man-
Manager, believes the LAN benefits all train- abbreviated two hour TeamSTEPPS Essentials agement of resources and workload
ers/coaches as they drive for sustainment of module is available and strongly recommend- With the formation of the TeamSTEPPS
changed behaviors. They are challenged to ed for department staff who do not provide curriculum, HCTCP has developed an evi-
focus on specific tools. For example, the focus direct patient care, but are vital to care plan- dence-based approach to team effectiveness
of the June call will be on the SBAR (Situation- ning or execution (e.g., laboratory, dietary which can be used in all facilities, from small
Background-Assessment-Recommendation) staff). ambulatory clinics to large medical centers.
tool, a technique that provides a framework Implementation and sustainment of TeamSTEPPS is the foundation to creating a
for communication among members of the teamwork performance is as critical on the safety net throughout military medicine. (In
healthcare team about a patient’s condition. back end as leadership and the change teams collaboration with the AHRQ, plans are also
The call will include four guest speakers, three are in the beginning of the team training underway to make TeamSTEPPS available to
from civilian healthcare systems where SBAR process. Sustainment requires strong com- civilian healthcare organizations this sum-
has been successfully implemented. munication, visible senior leadership sup- mer). To ensure that MTFs and other health-
Training requires a time commitment of port, coaching and role modeling, use of care delivery systems are aware of the Team-
two and one half days for the Train-the-Train- metrics to showcase improvement, and the STEPPS training opportunity, HCTCP is
er course, which is designed for the healthcare recognition and celebration of small success- developing a “smart book”. The intent of this
team training coaches and instructors who es. The goal of TeamSTEPPS is to facilitate a guide, which will be available late summer, is
will deliver the TeamSTEPPS curriculum. shift to a culture of teamwork – where team to provide leadership with a high level sum-
This course covers TeamSTEPPS fundamen- effectiveness becomes part of the mission, mary on how to plan, train and implement a
tals, change management and culture change, vision and values of the MTF, and is success- teamwork improvement project.
coaching, and implementation workshops. fully inculcated into every facet of the organ- For more information about TeamSTEPPS
Once trained, coaches from the facility cus- ization. The reward of TeamSTEPPS training a c c e s s t h e Te a m S T E P P S w e b s i t e a t :
tomize TeamSTEPPS materials used to train is to experience the many benefits of team- http://www.usuhs.mil/cerps/index.team-
on-site staff. The Train-the-Participant phase work: a significant reduction in observed stepps.html, available beginning June 15, 2006.

PATIENT SAFETY SPRING 2006 5

 PATIENT SAFETY LINKS PATIENT SAFETY
Interesting Resources To Explore PROGRAM NEWSLETTER
Published quarterly by the Department of Defense
charge of his/her own health and get (DoD) Patient Safety Center to highlight the progress
SAFETY ALERTS…SAFETY the best treatment available. Citing of the DoD Patient Safety Program.
ALERTS…SAFETY ALERTS research that the “safest patient is the DoD Patient Safety Program
Joint Commission on Accreditation educated patient”, readers are advised Office of the Assistant Secretary
of Healthcare Organizations on choosing the best hospital and of Defense (Health Affairs)
http://www.jointcommission.org/Sen- physician, avoiding medication errors, TRICARE Management Activity
tinelEvents/SentinelEventAlert/sea_36. advocating for themselves, and are Skyline 5, Suite 810, 5111 Leesburg Pike
Falls Church, Virginia 22041
htm provided with website resources for 703-681-0064
Sentinel Event Alert – Issue 36, April 3, gathering reliable health information. Forward comments and suggestions to:
DoD Patient Safety Center
2006 Armed Forces Institute of Pathology
Tubing Misconnections USA Today 1335 East West Highway, Suite 6-100
Silver Spring, Maryland 20910
An important and under-reported http://www.usatoday.com/news/health Phone: 301-295-7242
Toll free: 1-800-863-3263
problem in health care, tubing miscon- /2006-04-17-wrong-surgery_x.htm DSN: 295-7242 • Fax: 301-295-7217
nections are often caught and correct- “Wrong Site Surgeries On the Rise” E-Mail: [email protected]
Website:https://patientsafety.satx.disa.mil
ed before injury occurs; still the poten- describes findings of AHRQ study E-Mail to editor: [email protected]
tial for serious harm remains. JCAHO, published in Archives of Surgery, and DIVISION DIRECTOR,
citing reports of nine sentinel events provides comments from JCAHO and PATIENT SAFETY PROGRAM
LTC Steve Grimes
resulting in eight deaths related to tub- patient safety experts, as well as box DIRECTOR, PATIENT SAFETY CENTER
ing misconnections, provides recom- entitled “Don’t Become a Victim” with Geoffrey Rake, MD
mendations to minimize their occur- JCAHO recommendations for avoid- DIRECTOR, CENTER FOR EDUCATION
AND RESEARCH IN PATIENT SAFETY
rence, including increased awareness ing wrong site surgery. To compare the Eric S. Marks, MD
and specific safety procedures on the “popular” interpretation with the actu- DIRECTOR, HEALTHCARE TEAM
COORDINATION PROGRAM
part of providers, and a call for al study, see Ms. Heidi King
improved design by manufacturers. Archives of Surgery SERVICE REPRESENTATIVES
ARMY
http://archsurg.ama-assn.org/cgi/con- Major Robert Durkee
Center for Education and Research tent/full/141/4/353 NAVY
Ms. Carmen Birk
in Patient Safety April 2006, 141(4): 353-7; discussion AIR FORCE
Lt Col Kathryn Robinson
http://www.usuhs.mil/cerps/new/Safet 357-8 PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
yAlert08_Transdermal0Fentanyl.pdf “Incidence, Patterns and Prevention of Phyllis M. Oetgen, JD, MS
Patient Safety Center Alert – Issue 8, Wrong-Site Surgery”
March 31, 2006 Study results show that wrong-site sur-
Fentanyl Transdermal Patches gery is unacceptable, but exceedingly DoD PATIENT SAFETY WEBSITE
The DoD Patient Safety Program now sponsors two
PSC reiterates previous warnings in rare. Acknowledging that wrong-site websites to enhance communication of Program
details and patient safety information.
light of continued events associated surgery is “shocking to the public” The official DoD Patient Safety Website is accessible
with use of patches. Among other authors suggest protocols to ensure at: https://patientsafety.satx.disa.mil. This is the
source of the most current information about the
actions, PSC recommends facilities safety be simplified to improve adher- Patient Safety Program. It provides information on
consider a “safety stand-down” to ence and efficiency. the structure and initiatives of the Program, its vari-
ous components and related activities. The site
ensure providers are aware of proper includes a calendar of events, a link for patient safety
training registration, marketing and educational
dosage and use, and inclusion of warn- Time Magazine materials, and Patient Safety Program Tools. There is
ing in CHCS drug file comment. http://www.time.com/time/archive/pr a full archive of the Patient Safety Newsletters. Look
to this site for announcements from the Patient Safe-
eview/0,10987,1186553,00.html ty Program, such as the annual call for submissions to
PATIENT SAFETY HITS THE NEWS May 1, 2006 the Patient Safety Awards.
The Center for Education and Research in Patient
Joint Commission Resources What Doctors Hate About Hospitals Safety (CERPS), the educational component of the
http://www.jcrinc.com/generic.asp?du This issue of Time Magazine includes Patient Safety Program, provides a dynamic resource
on its own website at: https://www.usuhs.mil/cerps/-
rki=12514 an article entitled “Q: What scares doc- index.shtml. The CERPS focus is on educational
Oprah featured “You: The Smart tors? A: Being the patient”, which looks resources specifically targeted to professional stake-
holders, and on training information and opportuni-
Patient” as part of her show themed at medical errors from the perspective ties. There is an interactive component which is
linked to didactic training modules. Providers are
“90 Day Live Longer, Feel Younger of physicians who are patients them- directed to a number of patient safety resources, and
Plan”. Co-authored by Michael F. selves, or whose loved one is the will find the most current alerts and practice recom-
mendations on this site.
Roizen, M.D. and Mehmet C. Oz, patient. Even physicians well-informed Together, these related websites provide an integrated
M.D., in collaboration with Joint about safety issues report feeling a lack approach to communicating the scope, efforts and
message of the DoD Patient Safety Program. All DoD
Commission Resources, the book of control over their environment patient safety providers are encouraged to make fre-
explains how every patient can take while being treated. quent access to both websites a routine part of their
practice protocol.

6 SPRING 2006 PATIENT SAFETY