The DoD Patient Safety Program eBulletin delivers patient safety updates, news, useful tips and resources. This month’s issue spotlights the High Reliability Organization concept and how it applies to the Military Health System. You can also check out a Patient Safety Awareness Week follow-up article, a Sentinel Event Spotlight and much more. Enjoy!

Contents

Announcements/Reminders

Feature: High Reliability Organizations – An Overview*

Patient Safety Awareness Week 2015: How did You Celebrate? The DoD Patient Safety Program Wants to Hear from You!

DoD PSP Annual Summary Fiscal Year 2014 (Upcoming April 2015)

Sentinel Event Spotlight: Unsterile Medical Equipment in the Operating Room (Upcoming April 2015)

PSR Data Pulse Update

Upcoming Events

Patient Safety Reading Corner

Announcements/Reminders

• In April, the Military Health System will focus on Sexual Assault Prevention. Learn more.
• Save the date for the 2015 TeamSTEPPS® National Conference in Denver, Colorado 16-18 June. Learn more.
• Access TeamSTEPPS® 2.0 video training tools here.
• Access the DoD PSP’s Resource Guide and access tools and solutions to help ensure the safe delivery of health care in the Military Health System.
• The Basic Patient Safety Manager (BPSM) course is a five-day, highly interactive course designed for new Patient Safety Managers. Learn more.
• The 17th Annual NPSF Patient Safety Congress hosted by the National Patient Safety Foundation is taking place is right around the corner. Learn more.
• Running low on your DoD PSP materials? Click here to order what you need today!
• Featured DoD PSP Toolkit: Professional Conduct
• Talk to us! Do you have an update from your facility? Let us know via email or Facebook.

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Feature: High Reliability Organizations – An Overview*

The Military Health System (MHS) has always been committed to continuous improvement. As a result, last summer the Secretary of Defense directed a 90-day review of the MHS with a focus on...Read more

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Patient Safety Awareness Week 2015: How did You Celebrate? The DoD Patient Safety Program Wants to Hear from You!

The week of 8-14 March, 2015 was National Patient Safety Awareness Week sponsored by the National Patient Safety Foundation. This year’s theme was “United in Safety” and highlighted the importance of...Read more

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DoD PSP Annual Summary Fiscal Year 2014 (Upcoming April 2015)

The FY2014 DoD PSP Annual Summary contains aggregation and analysis of the patient safety events, submitted by the Services, occurring up to...Read more

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Sentinel Event Spotlight: Unsterile Medical Equipment in the Operating Room (Upcoming April 2015)

This Sentinel Event Spotlight will focus on sentinel events and RCAs within the MHS related to the use of unsterile medical equipment in the operating room. Identified causal and contributing factors leading to...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

TeamSTEPPS for Code Blue Teams: Piloting SBAR and CUS for Interprofessional Team Education

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

AHRQ is hosting a complimentary webinar on April 8 from 1 to 2 p.m. ET. In this webinar, Edward Lee, MD, Assistant Clinical Professor, Hospitalist Section in the UCLA Department of Internal Medicine, and Ken Miller, RN, MSN, CCRN, Simulation Education Program Coordinator in the UCLA Department of Nursing Practice Research and Education, will discuss how they identified the need for and implemented TeamSTEPPS tools in UCLA's Code Blue Teams. Specifically, this presentation will:

• Provide an overview of Code Blue Teams and interprofessional team training at UCLA
• Describe the identification of the need for TeamSTEPPS tools among Code Blue team members
• Describe how SBAR and CUS are being implemented
• Describe the plan for measuring the effectiveness of the intervention

Register now

Professional Learning Series | Topic: Medication Reconciliation Best Practices National Patient Safety Foundation**

16 April, 2015 from 2:00 p.m. to 3:00 p.m. EST

Speaker:
Jeffrey L. Schnipper, MD, MPH, FHM
Director of Clinical Research, BWH Hospitalist Service
Associate Physician, Division of General Medicine, Brigham and Women's Hospital
Co-Chair, Partners Clinical Performance: Transitions in Care
Associate Professor of Medicine, Harvard Medical School

Register now

DoD Patient Safety Learning Circle: High Reliability Organizations (TENTATIVE)

28 April, 2015 from 2:00 p.m. to 3:00 p.m. EST

Speakers: Heidi King and TBD

Objectives:

• Define a high reliability organization (HRO)
• Identify some characteristics and traits of a HRO
• Describe the direction of MHS relative to HROs
• Discuss Service progress toward HRO

Register now
This event is DoD-only

Data Dialogue: DoD PSP Annual Summary Fiscal Year 2014*

29 April, 2015 from 2:00 p.m. to 3:30 p.m. EST

After attending this Learning Circle, learners will better understand trends and analysis, along with process issues most associated with harm, related to frequently occurring patient safety events throughout the Military Health System (MHS) in fiscal year (FY) 2014. Patient Safety Reporting System (PSR), sentinel event (SE) notification, and root cause analysis (RCA) data garnered from the MHS for patient safety events will be discussed, along with relevant, evidence-based risk mitigation tools and strategies.

Register now
This event is DoD-only

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 CE-eligible. All CE credits are managed by Duke University Office of Continuing Medical Education.
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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.

• Defense Health Agency: Compound Drug Policy to Improve Patient Safety
• Accelerating the Adoption of a Safety Culture - The Joint Commission
• Pensacola Naval Hospital Room of Errors Improves Care
• AHRQ Funding Opportunity for Patient Safety Research

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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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