The DoD Patient Safety Program eBulletin delivers patient safety updates, news, useful tips and resources. This month’s issue spotlights patient engagement – a tenet of patient safety and high quality health care. You will also be able to access our latest Sentinel Event Spotlight, information on upcoming educational events and much more. Enjoy!

Contents

Announcements/Reminders

Feature: Patient Engagement across the Military Health System – An Overview

Continuing Education Update: Postgraduate Institute for Medicine Instructions and News

Patient Engagement: Understanding Barriers and Challenges from a Patient’s Perspective

Announcing the 2015 Quality and Patient Safety Awards

Sentinel Event Spotlight: Fires in the Operating Room/Surgical Fires

PSR Data Pulse Update

Upcoming Events

Patient Safety Reading Corner

Announcements/Reminders

• In July, the Military Health System will focus on Health Innovation. Learn more.
• Did you hear about the Continuing Education news? Be in the know.
• Access the National Patient Safety Foundation’s “RCA2 - Improving Root Cause Analyses and Actions to Prevent Harm” report here.
• Do not miss the Health IT Safety Center Webinar Series sponsored by the Office of the National Coordinator for Health Information Technology. Register now.
• Access the Patient Safety Reporting Intermediate course to develop the decision-making skills you need to effectively manage patient safety event data in PSR.
• Access Ask Me 3 materials and get tips on how encourage patients to become active members of their health care team.
• Check out the latest Joint Commission leadership podcast “Taking Time Out Before Procedures: A Team Effort” here.
• Is it time to replenish your DoD PSP materials? We’ve got you covered! Order what you need here.
• Activated patients have the knowledge and skills to make informed decisions about their health care. Access the Patient Activation Reference Guide and learn more.
• Talk to us! Do you have an update from your facility? Let us know via email or Facebook.

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Patient Engagement across the Military Health System – An Overview

Today, numerous efforts developed in response to the 90-Day Military Health System Review conducted in 2014, are underway and place patient engagement at the...Read more

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Continuing Education Update: Postgraduate Institute for Medicine Instructions and News

Dear patient safety professsionals, as we have shared with you in the past couple of months, we just transitioned to the new Continuing Education provider – the Postgraduate Institute of Medicine, effective 30 June 2015...Read more

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Patient Engagement: Understanding Barriers and Challenges from a Patient’s Perspective

TeamSTEPPS®, TEAM UP and the Patient Activation Reference Guide – these are just three of the currently available tools designed to help patient safety professionals across the MHS to...Read more

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Announcing the 2015 Quality and Patient Safety Awards

The Quality and Patient Safety Award program recognizes the excellence and dedication of patient safety professionals to deliver the best possible care to...Read more

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Sentinel Event Spotlight: Fires in the Operating Room/Surgical Fires

This Sentinel Event Spotlight focuses on sentinel events within the MHS related to fires occurring in the Operating Room. Surgical fires can occur any time in the...Read more

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PSR Data Pulse Update

Released on the 16th of every month, this report offers a snapshot of PSR events reported. This one page document provides a...Read more

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Upcoming Events

Patient Safety Learning Circles:
In-person or web-based forums focused on a specific topic

Health IT Safety Center Webinar Series – The Office of the National Coordinator for Health Information Technology

December 2014 through December 2015

This is a series covering a wide range of patient safety topics and will feature prominent quality and patient safety experts from across the U.S. Do not miss out!

Register now

Partnering with your Malpractice Insurance Program to Improve Safety in Surgery: TeamSTEPPS® as Part of a Multi-faceted Program – Agency for Healthcare Research and Quality

8 July, 2015 from 1:00 p.m. to 2:00 p.m. EST

In this complimentary webinar, David L. Feldman, MD, MBA, CPE, FACS, Chief Medical Officer and Senior Vice-President at Hospitals Insurance Company, will discuss patient safety in surgery from the risk management perspective. He will discuss a multi-hospital safe surgery collaborative that includes TeamSTEPPS as part of a multi-faceted program. The presentation will seek to:

• Describe how a malpractice insurance company can facilitate a safe surgery collaborative to help mitigate risk and improve surgical outcomes
• Discuss how to achieve high-level engagement with clinical departments in a multi-hospital collaborative
• Discuss the components of a multi-faceted safe surgery program and where TeamSTEPPS fits in
• Describe the metrics that can be used to show results from a safe surgery program

Register now

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm  National Patient Safety Foundation**

15 July, 2015 from 1:00 p.m. to 2:00 p.m. EST

At the end of this complimentary webinar, participants will be able to:

• Identify methodologies and techniques leading to more effective and efficient RCAs
• List tools to improve the process of completing RCAs to increase patient safety
• Identify and demonstrate tools that assist management in the evaluation process
• Identify advantages and techniques of employing explicit risk-based prioritization techniques for determining which patient safety related hazards and vulnerabilities require intervention
• To have a clear and credible report that identifies root causes and suggests strong, viable improvement strategies

Featured Speakers:
James P. Bagian, MD, PE
Director
Center for Health Engineering and Patient Safety
University of Michigan

Doug Bonacum, CSP, CPPS
Vice President, Quality, Safety, and Resource Management
Kaiser Permanente

Register now

Patient Safety Workshops:
Instructor-led or self-paced online learning sessions focused on a specific product

On-Demand eLearning: Patient Safety Reporting System v1.1 eLearning Course

This course introduces basic navigation and functionality features of the PSR system and the roles of system users, such as event reporters, event handlers, and investigators. The course can be accessed through MHS Learn.
Register now

On-Demand eLearning: Patient Safety Reporting: Intermediate Course*

Targeted to Patient Safety Managers and other MTF staff already familiar with basic functionalities of the Patient Safety Reporting System, this course is designed to help learners hone the decision-making skills needed to effectively manage patient safety event data in PSR, as part of the ongoing effort to eliminate preventable harm at MTFs.
Register now

On-Demand eLearning: Root Cause Analysis*
This self-paced module outlines the Patient Safety Program’s suggested practices for conducting a root cause analysis, from the initial reporting of a patient safety event through the formation of the RCA Team to the identification of contributing factors and root causes and the recommendation of corrective actions.
Register now

*Denotes that activity is eligible for CE credit. All CE credits are managed by Duke University Office of Continuing Medical Education. (Attention! Effective 30 June, 2015, the Postgraduate Institute for Medicine (PIM) will begin accreditation for patient safety activities across the MHS. Learn more)

**Did you know? As an NPSF Stand Up for Patient Safety member, DoD PSP receives complimentary access to webinars as a benefit of program membership. Check with your facility POC to obtain the member coupon code.

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Patient Safety Reading Corner

These articles are external and provided for information purposes only. The DoD does not sponsor these websites.

• Ambulatory Computerized Prescribing and Preventable Adverse Drug Events
• RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, NPSF Report
• AHRQ Hospital Survey on Patient Safety Culture: Public Comment on Version 2.0
• Updated Hospital Consumer Assessment of Health Care Provider and Systems Fact Sheet

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Do you have a learning activity or networking opportunity that should be included? Email us here: patientsafety@dha.mil.

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