INSIDE: Patient Safety Awareness Week Insert

SPRING 2009 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

HEIDI KING RECEIVES

NATIONAL PATIENT SAFETY FOUNDATION
CHAIRMAN’S MEDAL
National Award Recognizes Leadership In Patient Safety

M
s. Heidi King, Director, Department of Defense
(DoD) Healthcare Team Coordination Program
since 2002 and currently Acting Director, DoD
Patient Safety Program received the prestigious National
Safety Foundation Chairman’s Medal on May 21, 2009.
Presented at a special ceremony during the National Patient
Safety Foundation (NPSF) Annual Congress, the medal
recognizes emerging leadership in the field of patient safety.
It is awarded to an individual who has demonstrated the
ability to inspire, to lead and to effectuate measurable posi-
tive change and improvement within a culture of respect,
openness, learning and team dynamic.
Ms. King’s visionary, motivational leadership and relent-
less determination to accelerate widespread improvements
in patient safety have resulted in several DoD-led outreach
and collaborative efforts, most notably the internationally
successful TeamSTEPPS program, developed by the DoD
in partnership with the Agency for Healthcare Research and
Quality (AHRQ). Pamela Austin Thompson, RN, MSN,
FAAN, Chair of the NPSF Board, described the Chairman’s
Medal as the “highest award” bestowed by the Foundation.
In her presentation remarks, she recognized Ms. King as an
“innovator whose work has had a far-reaching impact on the
field of patient safety”.
The many DoD leaders and providers who have worked
under Ms. King’s leadership as TeamSTEPPS champions,
trainers and practitioners readily attest to her inspiration,
tenacity and passionate personal commitment. It is with Heidi King, Acting Director, DoD Patient Safety Program, receives National
great pride that all involved in the important DoD mission Patient Safety Foundation (NPSF) Chairman’s Medal from NPSF Board Chair
of keeping our patients safe say CONGRATULATIONS Pamela Austin Thompson, RN, MS, FAAN (middle). With them, left to right
to Ms King for her well-deserved national recognition, and are former NPSF board chairs Paul Gluck, MD; Carol Ley, MD, MPH; Timothy
THANK YOU to a leader of uncommon vision and skill. Flaherty, MD.  Photo taken by Event Digital Photography, Inc.

TABLE OF CONTENTS 5 Fall Conference Highlights 6 PSP News 8 TRICARE Patient Safety Month
NATIONAL PATIENT SAFETY FOUNDATION CONGRESS HIGHLIGHTS
DoD Providers Attend Congress, Award Presentation Culminates Busy Day
Pictured, left to right: Theresa Clark, Mountain
Home AFB, Idaho; Carole Durant, Elmendorf
AFB, Alaska; Scott Chittenden, Yokota AFB,
Japan; Marcia Vondran Lutz, Mountain Home
AFB, Idaho; Suzanne Berrong, Aviano AFB,
Italy; Judy Criner, PhD, RN, Joint Commission
Readiness Consultant, Tripler AMC, Hawaii.
Heidi King, Acting Director DoD Patient Safety
Program, addresses distinguished members of
the Lucian Leape Institute and the NPSF audi-
ence after receiving the Chairman’s Medal. Photo
taken by Event Digital Photography, Inc.
COL James Black, Senior Medical Director, TRI-
CARE Management Activity, Heidi King, NPSF
Chairman’s Medal recipient, and Jack Smith, MD,
Acting Deputy Secretary of Defense for Clinical
Policy at the National Patient Safety Foundation
Conference.
2 SPRING 2009 Patient safety
DOD PROVIDERS ATTEND NPSF CONFERENCE A large contingent of
DoD patient safety staff from across the Military Health System attended the Na-
tional Patient Safety Foundation Congress. Patient Safety Managers Scott Chitten-
den, Yokota AFB and Marcia Vondran Lutz, Mountain Home AFB talked about the
Conference and TeamSTEPPS. Scott Chittenden found that patient safety expert
Lucian Leape’s comments resonated with his experience: “Dr. Leape said that the
two most important things necessary to reform healthcare are teamwork and the
resources to implement it. We’ve found at Yokota medical care is at its best when the
team is complete”. Vondran Lutz says that providers at Mountain Home AFB find
TeamSTEPPS “very valuable”. They have enhanced their experience by adding the
DoD HFACS human factors component to their program, which they believe has
helped reduce same event errors.
HEIDI KING ACCEPTS AWARD The NPSF Chairman’s Medal was presented
at the Lucian Leape Institute Town Hall Plenary. A panel of nationally acclaimed
patient safety leaders witnessed the award ceremony: Paul O’Neill, former Treasury
Secretary; Dennis O’Leary MD, Pres. Emeritus, The Joint Commission; Julianne
M. Morath, RN, MS, Chief Quality and Safety Officer, Vanderbuilt Medical Center;
James A Guest, Pres., Consumers Union; Lucian Leape, MD, Harvard School of
Public Health; Janet Corrigan, PhD, MBA, Pres. & CEO, National Quality Forum;
Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality;
David Lawrence, MD, Kaiser Foundation Health Plan, Inc.; Donald M. Berwich,
MD, MPP, Pres & CEO, Institute for Healthcare Improvement. In accepting the
Chairman’s Award, Ms. King recognized the many dedicated providers from DoD
facilities. She told the NPSF audience:
“This would not be possible without our dedicated team working in the Department of Defense
Patient Safety Program and those in the field on the frontlines of care… We are energized by the
success stories we hear from our providers in the field on how they are preventing medical errors, stop-
ping them before they reach the patient. “We all play a vital role…If you are a care provider, make
every patient visit count by empowering your patients to become informed, active participants on their
care team. Leaders, renew your commitment to enable our most valuable asset — our people — to
provide safe care in a learning environment where they may openly communicate, work together, and
learn from their mistakes so that no other patient will be harmed from the same error.”
MHS LEADERSHIP CONGRATULATES AWARD RECIPIENT Heidi
King, Acting Director, DoD Patient Safety Program, poses at the National Patient
Safety Foundation Congress with COL James Black, Senior Medical Director, TMA,
and Jack Smith, MD, MMM, Acting Deputy Secretary of Defense for Clinical Policy
and Programs. COL Black shared these congratulatory comments:
It is my great pleasure to congratulate Heidi on being awarded the National Patient Safety
Foundation Chairman’s medal. She has inspired countless providers, nurses, and other healthcare
team members to embrace and execute TeamSTEPPS. The visible results of her efforts and the out-
pouring of positive and thankful comments from those in the field is a testament to her extraordinary
achievements.
TeamSTEPPS: A COMBAT VETERAN
10th Combat Support Hospital Adopts TeamSTEPPS; Shares Successes
O
ne year ago TeamSTEPPS was
successfully introduced to the 86th
Combat Support Hospital (CSH)
in Baghdad. In late November 2008,
with the support of the Patient Safety
Program’s Healthcare Team Coordina-
tion Program (HCTCP), TeamSTEPPS
was expanded to 10th CSH as part of
the overall plan to utilize TeamSTEPPS
throughout the combat theater. Over
1,000 military medical personnel serv-
ing in Iraq are currently TeamSTEPPS
trained. Now just one year after it first
went to war, TeamSTEPPS is an integral,
widespread part of the acute medical care
available to our wounded warriors.
Like their counterparts at the 86th
CSH, providers from the 10th CSH are
enthusiastic in their embrace of Team-
STEPPS. The successes they share
below are examples of TeamSTEPPS
principles at work in the midst of the
chaos and challenges of combat. Utiliz-
ing varied techniques, the theme is the
same –TeamSTEPPS training empowers
staff of every level and discipline to act
as a seamless unit for the benefit of the
patients they share.
SITUATION MONITORING
A Lifesaving TeamSTEPPS Lesson
TeamSTEPPS teaches providers to
reduce error by continually scanning and
assessing what is going on around them,
ensuring that changes are quickly caught.
Team members monitor each other’s
actions and provide a mutual safety net
within the team.
Constant situation awareness by team
members at the 10th CSH ensures that
any rapid and unpredictable deterioration
in the status of their patients is readily
observed, assessed and treated. In the
combat environment this TeamSTEEPS
tool has proven to be a particularly criti-
cal asset, as so many patients suffer from
complex trauma injuries which increase
the likelihood of unexpected changes.
Providers from the 10th CSH report that
all team members feel empowered by
TeamSTEPPS to assess potentially life-
threatening situations and take appropri-
ate action to keep patients safe. With its
shared focus on timely intervention and
collective responsibility, this Team-
STEPPS tool has allowed team members
no matter their rank or specialty to en-
gage and react, resulting in good catches
and saved lives at the 10th CSH.
HANDOFF and SBAR
COMMUNICATION TOOLS
What You Don’t Know
Can Hurt Your Patient
TeamSTEPPS places a high priority on
communication and provides a variety of
tools to ensure that patient information is
communicated among providers. During
transitions of care, the HANDOFF sends
critical information along with the patient
so that safety is not compromised because
significant facts are unknown. While car-
ing for a patient, providers are taught to
clearly and succinctly share actionable in-
formation using the SBAR technique – a
description of the Situation, Background,
Assessment and Recommendation.
In combat support hospitals like
the 10th CSH, host nation patients are
frequently treated. In addition to their
expected complex medical conditions,
these patients represent a diversity of
languages and cultures which often pres-
ent additional communication challenges.
Team members from the 10th CSH
report that the TeamSTEPPS Handoff
and SBAR tools have been especially
useful to them in caring for host nation
patients. These techniques have enabled
providers to quickly recognize incom-
plete reports from the field, perform
more systematic patient assessments, and
identify patients with critical conditions
that warrant higher levels of care. Staff
are confident that use of these structured
TeamSTEPPS tools has mitigated com-
munication difficulties, further prevent-
ing patient harm and saving the lives of
host nation patients.
THE HUDDLE
The Team that Huddles
Together Helps Together
TeamSTEPPS empowers each team
member to speak up, challenge and lead
when appropriate. The HUDDLE, an
ad hoc problem solving technique, al-
lows team members to reassess, rein-
force, or readjust plans as necessary to
assure the safety of their patient.
Team members from the 10th CSH re-
port that, in the dynamic arena of combat
medicine, the huddle is an ideal way to
reassess changing patient care conditions
and problem solve to provide the most
appropriate care. Transporting patients
from combat support hospitals to other
levels of care is a continuing necessity
and an on-going challenge. Transporta-
tion plans may need to be changed on the
tarmac if a patient’s condition deterio-
rates or a medevac helicopter or civilian
air ambulance lacks specialized equip-
ment. Teams from the 10th CSH rely on
the huddle throughout the transportation
process. They take a time-out on the
spot to redirect or reprioritize transporta-
tion plans when this is indicated, assur-
ing that patients are provided the safest
level of care from the time they arrive at
the 10th CSH to the moment they leave.
For over a year now TeamSTEPPS
has been utilized in the theater of opera-
tions. These successes from the 10th
CSH tell a tale of provider dedication
and enhanced patient care. They send a
clear message that TeamSTEPPS is help-
ing to keep our patients in the combat
zone safe from additional harm.
SPRING 2009 Patient safety 3
DoD LEADS IN LAPAROSCOPIC SURGERY TRAINING
Surgical Residents at MTFs Meet Certification Requirements
P
atients in Military Treatment Fa-
cilities (MTFs) across the Military
Health System (MHS) are assured the
highest level of safety when they undergo
laparoscopic surgery. Thanks to a partner-
ship between the National Capital Area
Medical Simulation Center (NCAMSC)
of the Uniformed Services University
(USUHS) and the DoD Patient Safety Pro-
gram (PSP), the certification program in
the Fundamentals of Laparoscopic Surgery
(FLS) has been introduced to the MHS.
FLS Certification Course, Tripler Army Medical Center (TAMC), March 2009. Maj E Matt Ritter
(NCAMSC, USUHS) reviews key information with TAMC OB/GYN residents and attendings.
FLS Certification Course, Tripler Army Medical Center (TAMC), March 2009. CPT Torie Plowden
and CPT Saioa Torrealday, TAMC OB/GYN residents practice their FLS skills.
4 SPRING 2009 Patient safety
The DoD efforts, which began in 2005,
followed national release of the FLS cur-
riculum.
Released in 2004 by the Society of
American Gastrointestinal and Endoscopic
Surgeons (SAGES) and the American Col-
lege of Surgeons (ACS), the FLS educa-
tional program consists of a didactic and a
manual skills component meant to improve
the level of patient safety during laparos-
copy. Major E. Matt Ritter, MD, currently
Chief of Minimally Invasive Surgery and
Emerging Technologies at USUHS, serves
on the SAGES FLS committee.
Building on his committee experience,
Major Ritter teamed with Col (ret) Mark W.
Bowyer, MD, Surgical Director at NCAM-
SC in 2005 and proposed a more ambitious
program which combined the FLS study
and certification in one training effort.
Because FLS certification is a prerequisite
for taking the American Board of Surgery
qualifying examination, the thirteen DoD
MTFs with residency training programs
have been the first to receive FLS training.
The training model introduced by Drs.
Ritter and Bowyer, with the support of the
DoD PSP, is premised on the identifica-
tion of a surgeon champion at each facility,
who attends a train-the-trainer course at
USUHS and returns to his or her MTF to
conduct the basic FLS training. Drs. Ritter
and Bowyer then schedule their one-day
training/testing course, which includes a
review of key information, a skills practice
segment, and administration of the certifi-
cation test.
As recognition of the link between im-
proved patient safety and FLS certification
has increased across the surgical commu-
nity, the DoD model has received national
attention. Covidien, a laparoscopic device
and equipment manufacturer, has provided
an educational grant to fund a similar pro-
gram to deliver FLS to civilian residency
training programs. Many civilian training
programs are using the Train the Trainer
deployment strategy developed by Drs. Rit-
ter and Bowyer and the PSP as their model.
The DoD FLS Patient Safety Program
goal that surgeons doing laparoscopic
surgery have, as a minimum, FLS certifica-
tion has resulted in reports of significant
improvement in safety related knowledge
among those trained. To date, nearly 200
surgical providers across the MHS have
been trained. This joint initiative promises
continued success and exemplifies the cre-
ativity and dedication the military brings to
its mission of keeping patients safe, within
its own walls and well beyond.
 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting

HIGHLIGHTS: PATIENT FALL REDUCTION CONFERENCE

DoD Co-Sponsors 10th Annual Event
Pamela Copeland, JD, RN, BSN
Patient Safety Analyst DOD CONFERENCE
The Veterans Administration (VA) and the University of South Florida sponsored PRESENTATIONS
the 10th Annual Patient Fall Education Conference held in Clearwater Florida May
4-8, 2009. For the first time the DoD Patient Safety Program (PSP) was a co-sponsor. Designating a Safe Room for
Representatives from all three services attended and DoD participation oc- Patients at High Risk for
curred at all levels of the conference. Dr. Geoffrey Rake, Director, DoD Patient Fall-Related Injuries
Safety Center (PSC), delivered opening remarks. John Courtney, Senior Systems LDCR Diane Hite, NC and Erin Lawler,
Analyst, Patient Safety Program, managed the PSP booth. National Naval Medical Human Factors Engineer, PSC
Center exhibited two posters. Conference sessions were presented by Carla Alexis, LCDR Diane Hite and Erin Lawler pre-
PT, Walter Reed Army Medical Center, and Erin Lawler, Human Factors Engineer, sented to a near standing room only audience
DoD PSC, and LCDR Diane Hite, NC, National Naval Medical Center. as they discussed critical design features that
The Conference focused on the latest research and suggestions for prevent- can either hinder or support falls prevention in
ing patient falls and reducing fall related injuries. Fall management strategies for a patient room. The presentation highlighted
various settings were presented, and special break-out sessions examined fall risks Evidence Based Design features and research
unique to particular populations. The Conference emphasized four main topics: relative to the built environment, as well as
categories of falls, components of a credible falls reduction program, populations technology and ergonomic considerations
at risk for greatest harm from falls, and technology to aid falls prevention. Of the that can influence the rate and severity of falls
numerous tips and strategies presented, highlights included: events. The duo ended by providing valuable
• Incorporate postural blood pressures in at risk patients for falls. tips to those who work in older environments
• Avoid using benzodiazepines in the elderly or spaces that may present hazards for falls.
• Use post-fall huddles to develop a team approach to treating falls “Make it Obvious” was the key take-away from
• Standardize the sitter process—develop training and competencies the session. They recommended that falls teams
• Discuss fall risk and interventions during shift changes and patient hand-offs increase visibility and situational awareness of
The 11th Annual Falls Conference will be held on May 3–7, 2010 in Clearwater, the hazards, as well as support features, that ex-
Florida. The DoD Patient Safety Program will again be a co-sponsor. Consider sub- ist in a patient room with low cost interventions.
mitting posters that showcase your facility’s innovative fall reduction efforts. Plan Orienting patients and families to these hazards
to attend with members of your fall team. Take advantage of this opportunity to and features, and bringing them in as partners
network with other fall champions and learn strategies and evidence-based consider- to the care process is a critical component.
ations that will challenge you to transform your facility’s fall reduction program.
Presentations and posters will be provided on request. Contact information for Special Issues Related to Fall Risks
presenters: Carla.alexis@us.army.mil; Lawlere@afip.osd.mil. Contact informa- in Traumatic Brain Injury
tion for posters: Mary.farley@med.navy.mil. Carla Alexis, PT, Walter Reed
Army Medical Center
Carla Alexis, PT, Traumatic Brain Special-
ist, presented the pathophysiology of vestibular
dysfunction in Traumatic Brain Injury (TBI)
patients. During the presentation, Ms. Alexis
stressed that a distorted sense of orientation,
which may be acute, intermittent or chronic,
may cause TBI patients to feel like the room is
spinning or they are walking sideways. Sugges-
DoD Falls Conference participants with Conference Program Director. Back row, l to r: ENS tions for managing patients suffering from TBI
Brad Respondek, NC, National NMC; Pamela Copeland, RN, DoD Patient Safety Center; ENS include taking a detailed history and customiz-
Henry Lang, NC, National NMC; Dr. Geoffrey Rake, Director, DoD Patient Safety Center; ing patient specific fall prevention interventions.
2nd Lt Kala Wehner, NC, Wright-Patterson AFB; Terri Sharpe, RN, Patient Safety Manager,
It is important, when changing the position of
Walter Reed AMC; Loma Moore, RN, Patient Safety Manager, Fort Meade; Rudy Lujan, Patient
Safety Manager, Wright-Patterson AFB; Dr. Gail Powell-Cope, James Haley VAMC; Dr. Patri-
a TBI patient, to do so very slowly. Reducing
cia Quigley, Program Director, 10th Annual Conference; front row, l to r: Violet Gordon, RN, provider bias that reported symptoms reflect
National NMC;  LCDR Diane Hite, NC, National NMC; Judith Miller, RN, National NMC; PTSD, rather than vestibular dysfunction is an
ENS Koa Thomas, NC, National NMC; Carla Alexis, PT, Walter Reed AMC; Erin Lawler, MS, on-going challenge.
DoD Patient Safety Center. Photo Taken By: Andrea M. Spehar.

SPRING 2009 Patient safety 5

 PATIENT SAFETY PROGRAM INITIATIVES
Opportunities for the Field
The Patient Safety Program is pleased to share the following updates on system-wide
initiatives that resonate across the entire scope of the MHS patient safety efforts.

PATIENT SAFETY PROGRAM LEADERSHIP TRANSITIONS

COL Steven Grimes Retires; Successor is LTC Donald Robinson, MD

C
OL Steven W. Grimes, United States
Army, Nurse Corps, has retired from
U.S. Army and his position of Direc-
tor, DoD Patient Safety Program (PSP).
Director since August 2005, COL Grimes
distinguished himself as a communicator,
a relationship-builder and a champion for
the Patient Safety Program. He worked
tirelessly to facilitate coordination and co-
operation among the services, and between
the Patient Safety Planning and Coordina-
tion Committee (PSPCC) leadership and
program providers. During his tenure,
COL Grimes facilitated the successful de-
ployment of three significant program-wide
initiatives -- the Patient Safety Culture Sur-
vey, a web-based patient safety reporting
system (PSR), and increased collaboration
with national patient safety organizations.
COL Grimes leaves his position having
firmly established the DoD Patient Safety
Program as a leader in national patient
safety efforts. He forged relationships with
the Veterans Administration (VA), the In-
stitute for Healthcare Improvement (IHI),
and with the Centers for Disease Preven-
tion and Control (CDC). Thanks to his
efforts, there is now an ongoing VA-DOD stronger for his efforts. This fall the Pro-
Joint Strategic Plan; the DoD participates gram will welcome its new director, LTC
in the IHI 5 Million Lives Campaign; and Donald Robinson, MD, a trauma surgeon,
a collaborative relationship exists between currently assigned to the Army Trauma
the DoD Infection Control Program and Training Center in Miami, Florida. In the
the National Healthcare Safety Network interim, Ms Heidi King will be acting Di-
(NHSN), the CDC’s web-based tool for rector of the PSP, assisted by Mike Datena
infection surveillance, aggregation and the acting Deputy Director.
analysis.
Within the PSP, COL Grimes leaves a
legacy of increased customer satisfaction
and communication. His belief that the
three Patient Safety Division components –
the Patient Safety Center (PSC), the Center
for Education and Research in Patient
Safety (CERPS), and the Healthcare Team
Coordination Program (HCTCP) – should
be better coordinated resulted in joint ef-
forts that made the entire Program greater
than the sum of its parts. In addition to
the long-awaited Patient Safety Reporting
System, COL Grimes’ efforts have inspired
a more user-friendly website, an enhanced
patient safety manager course, and the na-
tionally recognized TeamSTEPPS program.
Like all exceptional leaders, COL COL Steven Grimes, Director DoD PSP August
Grimes leaves the Patient Safety Program 2005 to April 2009.

DOD PATIENT SAFETY IMPROVEMENT GUIDE

Ideas for New PSMs Now Available!

T
he Patient Safety Program has de-
veloped an action-oriented guide to
assist new Patient Safety Managers
(PSMs). The idea for the guide originated
from the 2008 Tri-Service Survey on
Patient Safety Culture, with the desire to
share safety improvement practices under-
way throughout the Military Health System
(MHS).
The Guide includes:
• MHS results from the Tri-Service Sur-
vey on Patient Safety
• A procedure to take data and create an
action plan for safety improvement
• Patient safety activities and lessons
learned from selected MTFs
The Guide showcases select Military
Treatment Facilities (MTFs) based on their
culture survey scores amongst other fac-
tors. The factors include high overall scores
on the 2008 survey, score improvements
between the 2005/06 and 2008 surveys, Ser-
vice branch, facility type (hospital or clinic),
and facility size. Based on these criteria, nine
facilities were chosen to be interviewed. The
contents of the patient safety activities and
lessons learned reflect information obtained
through those interviews.
The Guide will provide new Patient
Safety Managers with ideas, lessons to
consider, and a framework to determine
which patient safety activities may offer the
greatest benefit for their facilities. The new
Patient Safety Managers will quickly notice
that there are no silver bullets to improv-
ing patient safety; rather, it takes leadership
commitment, individual persistence, and
the ongoing engagement of all staff.
To obtain the Improvement Guide, visit
the Patient Safety Program website:
http://dodpatientsafety.usuhs.mil.

6 SPRING 2009 Patient safety

 PATIENT SAFETY PROGRAM INITIATIVES
The Patient Safety Program is pleased to share the following updates on system-wide
initiatives that resonate across the entire scope of the MHS patient safety efforts.
PATIENT SAFETY REPORTING SYSTEM UPDATE
Developmental Testing and Evaluation to Begin
T
he Patient Safety Reporting (PSR) sys-
tem is a Tri-Service management sys-
tem that will automate patient safety
event reporting and help identify areas for
patient safety improvement in the MHS.
PSR will consolidate both medication and
non-medication event reporting into one
system and will enable the MHS to capture,
track, trend healthcare events, aggregate
de-identified information for reporting and
standardize reporting across the enterprise.
PSR provides a systematic methodology to
reduce the frequency and severity of medical
events by incorporating comprehensive anal-
ysis tools to identify enterprise-wide safety
improvement strategies.
PSR has completed configuration for
the initial nine test sites and began devel-
opmental test and evaluation (DT&E) on
HOSPITAL RAPID RESPONSE SYSTEMS TRAINING TOOL AVAILABLE
AHRQ and DoD Release New Team Training Module
A
new team training tool on Rapid
Response Systems (RRS)recently has
been released as a collaborative effort
by the Agency for Healthcare Research
and Quality (AHRQ) and the Department
of Defense (DoD). This new training
module, designed for use by hospital teams,
complements the Teams Strategies and
Tools to Enhance Performance and Patient
Safety (TeamSTEPPST) module, published
in 2006.
Research suggests that after implement-
ing a Rapid Response System, hospitals
experience a decrease in the number of
cardiac arrests, deaths from cardiac arrest,
the number of days in the intensive care
unit and the hospital overall post arrest,
and inpatient death rates. This new module
provides an overview of the Rapid Re-
sponse System and the role of the Rapid
Response Team, which is composed of
clinicians who bring critical care expertise
to patients requiring immediate treatment
while under hospital care.
Opportunities for the Field
May 18, 2009. DT&E is the first step in • Naval Hospital Pensacola
system fielding and consists of an evalua- • Naval Hospital Camp Lejeune
tion and report to the Program Manager Air Force
on how well the system functions against • Malcolm Grow USAF Medical Center
requirements. After DT&E PSR will • Wilford Hall USAF Medical Center
proceed into System Qualification Testing • Davis-Monthan AFB Clinic
(SQT) which is the first time the func- In January 2010, live users will get their
tional user community gets to test the first chance to evaluate PSR. Following a
system. Following successful SQT the 30-60 day user familiarity period, Opera-
system is given the green light to proceed tional Test and Evaluation (OT&E) will be-
with limited deployment. The sites for this gin. OT&E will be run by an independent
initial deployment and the next round of testing agency and will evaluate the system
testing are: for suitability, survivability and sustainabil-
Army ity based on observations and interviews
• Madigan Army Medical Center with staff in the live environment. Assum-
• Martin Army Community Hospital ing successful OT&E, full implementation
• Kimbrough Ambulatory Care Center across the MHS direct care system would
Navy begin in July 2010.
• National Naval Medical Center
This evidence-based module is available for training instructors.
in CD format. Utilizing a set of vignettes Free copies of the new RRS module CD
demonstrating rapid response system prob- are available at: http://teamstepps.ahrq.
lems and solutions and curriculum slides gov/abouttoolsmaterials.htm or by call-
which can be customized to meet an insti- ing AHRQ’s publication clearinghouse at
tution’s unique needs, the module provides 800-358-9295.
insight into the core concepts of teamwork
as they are applied to the
Rapid Response system.
The module is accom-
panied by an Instructor
Guide. The Guide
includes a complete
course planning
package (suggested
lesson plans and
resources, and
tools for monitor-
ing, evaluation
and ongoing
coaching),
as well as a
complete set
of materials Sample slide from Rapid Response System Module.
SPRING 2009 Patient safety 7
MAY: TRICARE PATIENT SAFETY MONTH
Beneficiaries Encouraged to Actively Participate in Treatment

A
s part of its focus during May Patient Safety Month, TRI-
CARE encouraged beneficiaries to take an active role in
their medical care. The following article, contributed by
Patricia Opong-Brown, Public Affairs Division, TRICARE Com-
munications and Customer Service Directorate, explains the DoD
TEAM-UP Initiative.
A Checklist to Help TRICARE Beneficiaries
Be Active Members of their Health Care
Today’s patients can and should take an active role in their
medical care. During Patient Safety Month, TRICARE especially
wants to encourage beneficiaries to do just that. Patients who make
an extra effort to communicate with their health care providers,
as part of a team approach, can help build trust and improve their
provider-patient relationship.
TEAM UP Brochure used as
“It is important when something doesn’t seem part of the TEAM UP program

right that you speak up immediately to the

nurse or doctor who’s taking care of you” The following TEAM UP checklist will help beneficiaries com-
municate more effectively with their primary care managers (PCMs):
COL John Kugler, Director, TRICARE Office of the Chief Medical Officer, Team Together
practicing physician at DeWitt Health Care Network, Fort Belvoir, Va • Choose to be an active member of your care team.
• Invite persons close to you to be members.
The TEAM UP program is a Department of Defense (DoD) • Follow the TEAM UP steps.
initiative implemented at Madigan Army Medical Center at Fort Educate Yourself
Lewis, Wash. It encourages use of a checklist, which is available on • Ask members of your care team to repeat their names and
the TRICARE patient safety program Web site at http://dodpa- explain their roles.
tientsafety.usuhs.mil/teamup. “TEAM UP allows beneficiaries to • Know the plan for treatment and your role in it.
be more active in promoting safe, quality healthcare”, says Heidi • Write it all down.
King, Acting Director, DoD Patient Safety Program. Ask Questions
• Situation: What is gong on with my care now?
• Background: What information do I need to understand the
PATIENT SAFETY PROGRAM NEWSLETTER situation?
• Assessment: What are the options to consider?
Published quarterly by the Department of Defense (DoD) Patient Safety Center to highlight the progress of
the DoD Patient Safety Program. • Recommendations: What is gong to be done?
Manage your Medications
DoD Patient Safety ACTING DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM • Provide a list of medications (prescriptions, over-the-counter
Program Office of Ms. Heidi King
the Assistant Secretary and herbal remedies).
DIRECTOR, PATIENT SAFETY CENTER
of Defense (Health Geoffrey Rake, MD
• Write down what medications are prescribed and why.
Affairs)TRICARE ACTING DIRECTOR, CENTER FOR EDUCA-
• Read each medication label carefully
Management Activity TION AND RESEARCH IN PATIENT SAFETY • Alert the care team if a medication label does not match what
Skyline 5, Suite 810, 5111 Leesburg Pike Howard Steed, PhD was prescribed.
Falls Church, Virginia 22041
703-681-0064
DIRECTOR, HEALTHCARE TEAM Understand Changes in the Game Plan
COORDINATION PROGRAM • Listen to how the game plan has changed.
Ms. Heidi King
Forward comments and suggestions to: • Ask Questions.
SERVICE REPRESENTATIVES
DoD Patient Safety Center ARMY • Repeat the new game plan back to the care team.
Armed Forces Institute of Pathology LTC Anthony Bohlin Provide your Perspective
1335 East West Highway, Suite 6-100
Silver Spring, Maryland 20910
NAVY • Share all your feelings with your care team
Ms. Carmen Birk • Raise concerns immediately.
Phone: 301-295-7242
Toll free: 1-800-863-3263 AIR FORCE • Repeat the concern and include why it makes you uncomfort-
DSN: 295-7242 • Fax: 301-295-7217 Lt Col Anne Coyne
E-Mail: patientsafety@afip.osd.mil
able and how it may be a safety issue.
PATIENT SAFETY PROGRAM NEWSLETTER
Website: http://dodpatientsafety.usuhs.mil EDITOR For additional information about playing a more active role in
E-Mail to editor: poetgen@aol.com Phyllis M. Oetgen, JD, MSW personal health care, beneficiaries should talk with their PCM or
visit the Patient Safety Program website at: http://dodpatientsafety.
usuhs.mil/teamup.

8 SPRING 2009 Patient safety