The DoD Patient Safety Program eBulletin delivers patient safety updates, news, useful tips and resources. This month’s issue provides an update on key Military Health System 90-Day Review-related efforts currently underway across the enterprise, a Continuing Education update and our latest Focused Review. In addition, we invite you to check out our brand new sections: “Patient Safety Spotlight” highlighting the JB Elmendorf-Richardson Patient Safety Program and the new “High Reliability Organization (HRO) Corner” – a section that focuses on high reliability best practices and patient safety-focused examples applicable to what you do on a daily basis to keep your patient safe. Enjoy!

Contents

Announcements/Reminders

Feature: Update on Patient Safety Efforts Related to the Military Health System Review and High Reliability

Patient Safety Spotlight: 673 Medical Group, Joint Base Elmendorf-Richardson, Alaska – Talk to Me: Reducing Issues Related to Communication Initiative

HRO Corner: High Reliability Organization Guiding Principles and the Military Health System

Continuing Education Update: Online Registration Center Instructor Guidance

Sentinel Event Spotlight: Unintended Retained Foreign Object – Dental

Focused Review: Patient and Family EngagementPSR Data Pulse Update

Upcoming Events

Patient Safety Reading Corner

Announcements/Reminders

• In September, the Military Health System will focus on Suicide Prevention. Learn more.
• The 2015 Quality and Patient Safety Awards applications will be due on 9 October, 2015. Learn more!
• Running low on DoD PSP materials? Order badge cards, brochures, posters and more here.
• Registration is now open for the 2015 AHRQ Research Conference, "Producing Evidence and Engaging Partners to Improve Health Care," scheduled for October 4-6, 2015. Learn more.
• Access TeamSTEPPS 2.0 Core Curriculum information here.
• Did you hear about our Continuing Education vendor news? Be in the know.
• Access the Medical Team Performance Assessment Tool (MTPAT), a software application that supports the transition and sustainment of TeamSTEPPS principles, here.
• Featured DoD PSP Toolkit: Patient Falls Reduction.
• Talk to us! Do you have an update from your facility? Let us know via email or Facebook.

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Feature: Update on Patient Safety Efforts Related to the Military Health System Review and High Reliability

The Military Health System has always been committed to continuous improvement and the delivery of the highest quality of care to...Read more

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Patient Safety Spotlight: 673 Medical Group, Joint Base Elmendorf-Richardson, Alaska – Talk to Me: Reducing Issues Related to Communication Initiative

The DoD PSP team is thrilled to celebrate the outstanding efforts of the 673 Medical Group, Joint Base Elmendorf-Richardson Patient Safety Program! In June of 2015, a TeamSTEPPS® improvement project submitted by...Read more

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HRO Corner: High Reliability Organization Principles and the Military Health System

The DoD PSP team is excited to introduce the new HRO Corner section in our eBulletin! As the MHS continues its path toward becoming a High Reliability Organization, our team will...Read more

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Continuing Education Update: Online Registration Center Instructor Guidance

The Continuing Education team recently updated the Online Registration Center Instructor Guidance. Now, Course Coordinators have an...Read more

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Sentinel Event Spotlight: Unintended Retained Foreign Object – Dental

This Sentinel Event Spotlight will focus on sentinel events within the MHS related to retained foreign objects in the...Read more

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Focused Review: Patient and Family Engagement

Providing patient-centered care and fostering patient and family engagement leads to improved outcomes of care. The MHS, in its path 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

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

Addressing Behaviors that Undermine a Culture of Safety, Reliability and Accountability – Agency for Healthcare Research and Quality

9 September, 2015 from 1pm to 2pm EST

AHRQ is hosting a complimentary webinar on Wednesday, September 9 from 1 to 2 p.m. ET on the use of the agency's teamwork training program, TeamSTEPPS. Gerald B. Hickson, MD, who serves as the Senior Vice President for Quality, Safety and Risk Prevention, and Assistant Vice Chancellor for Health Affairs at Vanderbilt University Medical Center will focus on the issue of and challenges associated with team members whose behaviors undermine a culture of safety. Specifically, the presentation will seek to:

• Use a specific example of a team member's lack of compliance to illustrate a critical challenge with quality improvement interventions
• Describe the consequences of failure to address undermining behaviors
• Discuss strategies for addressing undermining behaviors
• Discuss the importance of teamwork in compliance and the sustainment of a culture of safety, reliability and accountability

Register now

Overuse of Health Care: Patient Safety Implications National Patient Safety Foundation**

16 September, 2015 from 1pm to 2pm EST

Learning Objectives:

• Recognize the potential risk of patient harm from overuse of tests, procedures, medication, physician visits, and hospitalization.
• Identify potential instances of overuse in clinical practices and institutions and become sensitized to its prevalence.
• Increase awareness of the potential for patient harm from overuse through discussions with colleagues and patients.

Featured Speaker:
Shannon Brownlee
Senior Vice President
Lown Institute

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. Attention! Effective 30 June, 2015, the Postgraduate Institute for Medicine (PIM) began 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.

• ASME Recognizes NPSF-Funded Research Study on Detecting Fall Risks
• New Targeted Solutions(R) Aims to Prevent Inpatient Falls - Joint Commission
• New Members of NPSF Governing Boards Announced
• New, Updated Resources Released for Preventing Surgical Fires Initiative - Joint Commission

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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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