INSIDE: NEW PATIENT SAFETY PROGRAM WEBSITE
SPRING 2007 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
MTFs PARTICIPATE IN PATIENT SAFETY
AWARENESS WEEK
Activities Vary In Support of Common Theme: “Patient Safety—A Road Taken Together”
The National Patient Safety Foundation
encouraged hospitals and health care
organizations nationwide to participate
in Patient Safety Awareness Week
(PSAW) March 4-March 10, 2007. Med-
ical Treatment Facilities (MTFs) across
the Military Health System responded
enthusiastically, focusing patients and
staff alike on patient safety and high-
lighting the collaborative nature of build-
ing a safe environment. The Patient Safe-
ty Program salutes the Patient Safety
Managers and all staff whose participa-
tion made these activities successful.
99th MDG
Nellis AFB, Nevada
The Patient Safety Working Group at Mike
O'Callaghan Federal Hospital capitalized
on their Las Vegas location to plan a week-
long observation highlighting the impor-
3–4 PSC News: NPSG Compliance, Human Factors Corner
tance of correct patient identification. Their
theme, We won't gamble with your safety,
permeated varied activities, from gaming
chip buttons, to posters, tent cards, laminat-
ed signs and electronic message boards.
Training, patient safety leadership rounds
and commander's calls further spread their
message and reinforced their commitment
to accurate patient identification.
325 MDG
Tyndall AFB, Florida
Patients at the 325th MDG were provided
with information on safe medication use.
Staff participated in a rousing game of
“Squadron Patient Safety Feuds” during a
March 7th commander's call. Weeks of prepa-
ration on patient safety and TeamSTEPPSTM
questions and answers contributed to the
competitive spirit, which is still going
strong—a May re-match has been scheduled.
SPRING 2007
6 CERPS: Microsystems
10th MDG
US Air Force Academy, Colorado
Although Patient Safety begins with an “S”, it
starts with YOU! This is the winning entry,
submitted by the Neurology Clinic, in the
10th MDG patient safety slogan contest,
which culminated its PSAW activities. While
staff played Patient Safety Poker and enjoyed
a patient safety scavenger hunt during the
week, patients were encouraged to partici-
pate in their medical care at an exhibit in the
main lobby, complete with a Spin-the-Wheel
game, informational handouts and a newly
developed “Health Journal” for patient use.
Pacific Air Forces
Medical units in bases across the Pacific
observed PSAW with activities that ranged
from daily safety-focused emails for staff to
booths, posters and displays for patients.
Especially creative was the “Room of
7 Tripler Rapid Response Team
AWARENESS WEEK
Continued from Page 1
Errors” display at Yokota, and the “Ask Me”
hand washing badges distributed at Misawa
in both Japanese and English.
AIR FORCES EUROPE
Staff members at the 48th MDG, Lakenheath,
England found themselves on “A Road Taken
Through Europe” during their PSAW activi-
ties. This twist on the official theme offered
staff a patient safety passport, and a tour of
the hospital where each area represented a des-
ignated country and displayed a poster project
showcasing improvements to patient safety.
Staff also visited the Room of Horror, where
they identified a host of patient safety errors.
Patient Safety Jeopardy was the highlight of
the 31st MDG activities in Aviano, Italy.
2 SPRING 2007 PATIENT SAFETY
Teams representing Dental, Pharmacy,
OB-GYN, Majors and MDG Super-
intendants/1st SGT competed, with
the Dental Squadron winning the first
Annual Championship.
Kimbrough Ambulatory Care Center
Ft. Meade, Maryland
Patient Safety Mardi Gras at Kimbrough
ACC was a colorful week-long celebration.
Patients received educational literature, and
were treated to a “shoe box” float display rep-
resenting National Patient Safety goals. Safe-
ty themed puzzles were emailed to staff, who
also visited a Room of Horrors and a Hand-
Hygiene/Washing station. A “Taste of New
Orleans” Pot Luck event completed the
PSAW revelry.
Brooke Army Medical Center
Fort Sam Houston, Texas
The Patient Safety Service at BAMC
ensured attention to patient safety by dis-
playing banners at both main hospital
entrances, and by hosting a week-long
patient safety booth in the Medical Mall.
Performance improvement coordinators
manned the booth, where literature,
handouts and demonstrations for both
staff and patients were offered. A Patient
Room of Safety and HIPAA violations was
set up for Staff to visit and compete in
identifying deficiencies.
DeWitt Health Care Network
Ft. Belvoir, Virginia
Staff at DeWitt were challenged during
PSAW to games of Readiness Roll. They were
asked accreditation related questions rang-
ing from patient safety rights and ethics to
quality assurance/risk management and
Joint Commission hodgepodge. Lunch
hours were the designated PSAW focus
times, with a display of educational materials
for staff and patients. The PSAW grand finale
was a poster contest, where prizes were
awarded and posters were displayed.
Naval Hospital, Pensacola
Pensacola, Florida
With a main hospital and eleven clinics in
four states as part of its command, Pensacola's
PSAW activities impacted a particularly large
audience of staff and patients. Displays
encouraged patients to become involved in
their own care, providing Ask Me and Speak
Up handouts, and My Medication cards at
Pharmacy windows. Games of patient safety
Jeopardy and Word Scramble were sent to
staff via email, and a Patient Room of Horrors
was maintained throughout the week. To fur-
ther spread the word, Patient Safety Manager
Stewart Weston published an article to coin-
cide with PSAW in Gosport, the home base
newspaper of the Pensacola Naval Air Station.
Naval Hospital, Bremerton
Bremerton, Washington
Blazing Trails to Patient Safety was the West-
ern-inspired theme of Bremerton's PSAW
week activities. Leadership from the Medical
Staff, Nursing Service and Ancillary Services,
jailed in the Quarterdeck, were freed by staff
who correctly answered Joint Commission
and Patient Safety questions. The presiding
judge represented the Department/Division
which demonstrated proactive patient safety
activities over the past year. Command com-
mittees participated by sponsoring a Com-
mand-wide Chili-cook off.
 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting
JOINT COMMISSION
NATIONAL PATIENT
SAFETY GOALS
Suggestions to Help With Compliance
Mary Ann Davis, RN, BSN, MSA
Patient Safety Manager, Patient Safety Center
Lt Col Paul Hoerner, USAF, Biomedical
Services Corps
Deputy Director, Patient Safety Center
T
he National Patient Safety Goals
(NPSGs) were developed to minimize
medical errors and to promote specif-
ic improvements in patient safety. Since
2003, the Joint Commission has surveyed
accredited medical treatment facilities
(MTFs) and checked for the implementation
of the NPSGs. Each year the Joint Commis-
sion reports the compliance rates for goal
implementation. The 2006 2nd quarter
NSPG compliance rate for all accredited hos-
pitals was below 80% for goals 1B, 2B, 2C,
and 8A1. The Patient Safety Center (PSC) has
reviewed relevant literature and information
from MTFs on these goals and offers the fol-
lowing actions and lessons learned to assist
with implementation and/or compliance.
Goal 1B.
“Time out”, part of the universal protocol
(required after 7/1/04) for preventing wrong
site, procedure, person surgery is essential
and must be conducted immediately before
starting a procedure.2 “Time out” has
expanded to include dental and separate
anesthesia procedures such as nerve blocks.
To facilitate time out:
• Emphasize active communication tech-
niques among staff and with patient;
verbalize what is being done.
• Require a separate “time out” immedi-
ately before an anesthetic block.
• Use two unique identifiers during “time
out” to verify correct patient.
• Attach a printed sign with laterality to the
fluoroscopy unit as a visual reminder of
the side being assessed during “time out”
and during the procedure.
• View digital radiological image as part
of the final “time out” process to
ensure that the radiologic images are
properly oriented.
• Empower all team members to “speak up”
with questions.
Goal 2B.
Standardizing the abbreviations, acronyms
and symbols that are not to be used is an
ongoing problem. There are several abbrevi-
ations that are considered dangerous or
unsafe to use. Consider:
• Distributing prohibited abbreviations,
rationale for not using them, and
acceptable alternatives to all depart-
ments and providers for quick reference.
• Distributing ID badges with list of the
unapproved abbreviations on the back.
• Laminating copies of the “do not use
abbreviation” list, with acceptable alter-
natives. Place in each patient's chart and
next to department telephones to assist
with verbal orders.
• Printing “do not use abbreviation”
list on florescent-colored paper as a
visual reminder. Post wherever orders
are written.
• Placing adhesive backed “do not use”
abbreviations cards on/near each com-
puter as a reminder to staff performing
data entry.
Goal 2C.
Critical test results and values must be report-
ed in a timely fashion. These can involve labo-
ratory tests, imaging studies, electrocardio-
grams and other diagnostic studies.3 To ensure
timely reporting:
• Maintain a prioritized list of critical test
values/interpretations that require
accelerated notification. 4
• Note the criticality of tests and designate as
critical in the electronic ordering system.
• Include ordering physician and location
on test requisitions. Ensure the labora-
tory has a mechanism to determine on-
call coverage.5
• If the computer system will not allow
more than one person to receive the lab
results, assign a surrogate provider when
the PCP is not available.
• For systems that automatically commu-
nicate results to the responsible
provider, include an acknowledgement
function to ensure that the result was
received. Create a prompt with an alter-
native communication approach when
•
acknowledgement is not returned.5
Have RN review results, personally pres-
ent significant results to provider, and
obtain sign-off of results. Place routine
/no follow up results in mailbox with a
weekly review of all lab results.
• Involve Pharmacy with PTT level; have
lab notify pharmacy and resident and
staff physician of PTT levels of 100
or above.
Goal 8A.
To accurately and completely reconcile
medications across the continuum of care6
is a laborious task. This goal was created
in 2005 and is still being implemented.
MTFs suggest:
• Create a multi-functional team to design
an effective and efficient medication rec-
onciliation (MR) process. Have Patient
Safety Managers collaborate for regional
or service specific lessons learned.
• Start the MR process when the admit-
ting nurse prints the inpatient admis-
sion MR form, reviews meds with
patient, and determines with provider
meds to be continued, stopped, or held
during admission. Place copy of MR
form in chart. Have Pharmacy print out
discharge MR form and review drugs
with patient. Utilize both Summary of
Care updates and outpatient drug pro-
file in AHLTA
• Have IT staff develop a AHLTA menu
item to retrieve a patient profile of drugs
dispensed from pharmacy, retail net-
work, and mail order (utilizing DoD
Pharmacy Data Transaction Service),
with headings for adding over-the-
counter drugs and supplements.
Provider reviews updated form with
patient and reconciles any changes in
drug therapy. At check-out patient gets
list of current drugs and tech updates
and initials DoD Form 2766.
• To ensure compliance, conduct a ran-
dom review (3-5 charts per provider)
of patient records and documented
provider compliance with medication
reconciliation.
For specifics of footnote references, please con-
tact Mary Ann Davis at davism@afip.osd.mil.
PATIENT SAFETY SPRING 2007 3
 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting

THE HUMAN
FACTORS CORNER
Integrating Human Factors and
Patient Safety
Erin Lawler, BA, MS
Design—the creation and/or implemen-
tation of things—affects nearly all aspects of
patient safety from medical supply packaging
to the way policies are implemented. Design
can enable the safe and effective delivery of
health care or it can significantly impede it.
Where HFE Can Help
Designing for individual factors physical strength and dexterity; anthropometrics and biome-
chanics; mental workload; information processing, fatigue, lim-
itations, capabilities, expectations, etc
Design of work job demands; process design; communication, teamwork;
required cognitive, physical and social skills, etc
Design of objects technology (software/hardware); equipment; medical supplies;
furniture, etc
Design of the work environment layout; ambient considerations of light, noise, temperature, etc;
organization of equipment and materials, etc
Organizational factors macroergonomics; safety culture; norms; organization type,
goals; resource availability; allocation of functions, etc

Patient considerations health condition; age; physical characteristics; cognitive ability;

Health care is a deeply complex system of communication ability; needs, etc

interacting components. A majority of root

causes for errors can be attributed to poor
design of equipment and technology; the
work environment; the processes, procedures,
staff communication, and tasks that define a Some Questions To Consider
job; and the interactions of these components
within the overall health care system. Could communication between team members be improved to ensure everyone is heard?

You may at times use medical devices
that seem needlessly complex or find that you
spend significant time walking back and forth
as you gather medical supplies. Lack of con-
sideration for the interaction of a person with
the equipment, spaces and people around
him or her can produce negative conse-
quences that range from staff frustration,
Can a process be better organized in terms of the tasks, team work, and work flow needs? Can a process be
simplified and made clearer?
Can equipment and medical supplies be better arranged according to frequency of use?
Is the work environment layout flexible and supportive of work patterns and tasks? Can the layout be
improved to reduce moving back and forth? Are there areas that are difficult to navigate?
Is there equipment or technology that is difficult to use or easy to misuse (physically and mentally)? Do you
have all the necessary information from the technology to make appropriate decisions?
Are lighting and acoustics optimal for the work? Are signals and warnings difficult to hear or see?

time delay and fatigue to more catastrophic

events of injury or death. Successful designs of
these interactions, on the other hand, match
the design of work environments, processes
and technology with the needs, expectations,
capabilities, and limitations of the users. This
user-centered focus is the foundation for the
field of human factors and ergonomics
(HFE): also known as human factors engi-
neering or “human factors.”
Human factors is a multidisciplinary applied
science that is “concerned with the under-
standing of interactions among humans and
other elements of a system…”(IEA, 2007). Put sim-
ply, it ensures that equipment, environ-
ments, processes and systems are “usable by
the people that are meant to use them”
(Lerner, Llaneras, Smiley, & Hanscom, 2005).
Human factors methodologies use a sys-
tems approach to assess how the compo-
nents and overall system operate under the
strain of real-work contexts. They build an
understanding of how an error occurs given
its context, and provide safer and more
comfortable design solutions to make it
more difficult, if not impossible, for errors
to recur.
What You Can Do
Start small; be proactive. If you see a possible
issue, discuss it. Human factors and
ergonomics is an empowering practice;
everyone involved in health care can partici-
pate. Just as you notice frustrations with
your room layout, the difficult design of a
can opener, confusing communications, or a
particularly dangerous intersection, begin to
open your mindset to how you operate in
your work environment and with equip-
ment, people and processes.
Human factors ergonomics should be an inte-
gral part of patient safety culture. To facilitate
this integration, the “Human Factors Corner”
column will address specific areas where HFE
methods can be applied in your facilities and
work areas, as well as general rules of thumb
relating to the National Patient Safety Goals
(NPSGs), and trends identified by the PSC. The
column will be interactive, responding to your
particular questions or issues regarding
human factors. To “Just ask Erin!” email:
lawlerl@afip.osd.mil or call: (301) 295-8125;
PSC Main Number (301) 295-7242.
For specifics of footnote references, please con-
tact Erin Lawler as above.

4 SPRING 2007 PATIENT SAFETY

 PATIENT SAFETY PROGRAM REVISES WEBSITE
New Address, New Content Offer
Improved Utility to Users
site with a single click, thus making it impos- Accessing the New Site
sible to get lost. Visual consistency has been Users are encouraged to visit the
enhanced by the use of color-codes, which new Patient Safety Website at
match the Patient Safety Program graphic on http://dodpatientsafety.usuhs.mil. Once you

T
he Department of Defense Patient the Welcome page, to designate CERPS (pur- have accessed the site, please bookmark it for
Safety Program (PSP) launched its ple), the PSC (red) and HCTCP (teal). A frequent return. It is intended to be a timely
new website in April 2007. The site is drop-down menu under each of these Pro- source of information on the Patient Safety
designed to support the mission and pur- gram components allows users to see the Program, its products, services and compo-
pose of the Patient Safety Program, as well content of each component at a glance. nents. It will serve as a repository of the
as to support the individual and collective Finally, News flashes are repeated below the Patient Safety Newsletter and other Program
missions of the Center for Education and left navigation bar in each section, so that publications, and will provide a link to exter-
Research in Patient Safety (CERPS), the timely information is accessible without the nal Patient Safety news.
Patient Safety Center (PSC) and the need to return to the Home page.
Healthcare Team Coordination Program
(HCTCP). Development of the Patient
Safety website is a three-phase project. The
currently available Phase 1 provides public
level access. Phase 2 will focus on user
groups, and will provide login capability to
view user specific and/or protected data
materials. The third phase will incorporate
interactive capabilities.

Benefits of the New Site

The Patient Safety website is meant to pro-
vide a central repository for all Patient
Safety Program information, which
includes information related to CERPS,
the PSC, and the HCTCP. It is being host-
ed on the Uniformed Services University of
the Health Sciences (USUHS) server.
Developed by the team of John Courtney
and Mary Stahlman from the Patient Safe-
ty Program office, David Poole, PSP Web-
master, and Eileen Song, CERPS Instruc-
tional Designer, the new website promises
reliable access to users. As the communica-
tion nerve-center of the Patient Safety Pro-
gram, it will be updated on a regular basis,
and will provide a one-stop source of
information related to patient safety
efforts across the Military Health System.
Dr. Eric Marks, Director of CERPS,
explains that the premise of the redesigned
website is “to help people do their jobs. It
is one more way to engage users in the
ownership of safety”.

Design Features of the New Site

The new website has been designed to maxi-
mize ease of use. The layout, with a banner
that mirrors other Patient Safety Program
publications, is clear and unfussy. A left-
sided navigation bar allows users to move
within the various site sections while retain- Home page of the redesigned Patient Safety Website:
ing the ability to return to any place on the http://dodpatientsafety.usuhs.mil.

PATIENT SAFETY SPRING 2007 5

MICROSYSTEMS
IN THE CLINICAL
ENVIRONMENT
CERPS Pilot Project Introduces
Conceptual Framework to MHS
A
re you working in an overwhelmingly
busy clinic or department where,
despite your best efforts, inefficien-
cies and frustrations seem the order of the
day? Have you often thought that you'd like
to improve how things work but you are so
busy doing your job that you don't have the
time? If your answers are yes, as they are for
staff in most complex health care environ-
ments, you should be particularly interested
in learning more about the microsystem
framework and its potential for transform-
ing patient care from the inside out.
In recent years, the microsystem has become a
focal point in efforts to improve health care.
Defined as “the small, functional, front-line
units that provide most health care to most
people”(Nelson EC, et al, Jt Comm J Qual Improv 28)
microsystems are the local milieu—the indi-
vidual department, clinic, or small group of
people working together on a regular basis to
provide care to a discrete population of
patients. Microsystems are the place where
patients and providers meet. Recognition is
growing that the quality and value of care
produced by a large health system can be no
better than the services generated by the small
systems of which it is composed.
The Center for Education and Research in
Patient Safety (CERPS) began a pilot project
in late 2006 at the Naval Hospital, Sigonella
and Vincenza Army Health Clinic to test
whether and how the microsystems concep-
tual framework can be successfully assimilat-
ed into the Military Health System. Com-
mand support was obtained, the pilot units
completed prework and created a team rep-
resenting every role in their units. CERPS
then held a three day training visit at each
site, where teams identified gaps or ineffi-
ciencies in how they worked, and launched
their first Improvement Action. Over a year
of CERPS supervised follow-up, further
improvements are expected within the units,
with team members being responsible for
continual assessment and positive change.
Dr. Diana M. Luan, PhD, RN, MPA, MS,
Senior Research Policy Specialist at CERPS
explains that the conceptual framework that
6 SPRING 2007 PATIENT SAFETY
Slide from CERPS microsystems training illustrating the elements of the microsystem
supports microsystems-based change takes
the work of Improvement (both quality and
safety) and reduces it to the smallest repro-
ducible unit—the SRU(Quinn, J. B. (1992). The
intelligent enterprise. New York, Free Press)—the inter-
face with the patient. The goal of a highly
functioning microsystem is to ensure that
each patient interface is the most effective,
most efficient, most productive possible. To
accomplish this, those working in the
microsystem reflect on the four P's—People,
Patients, Processes and Patterns (measure-
able outcomes)—of their particular unit. If a
unit understands all that is involved in the
four Ps, it is better able to tailor services to
the patient. Described as the “elementary
school” for further improvements by Dr.
Luan, assessing the microsystem does for the
work environment what medical providers
do daily in the clinical environment—it
identifies the basic steps in providing service,
assesses how they work, diagnoses and treats
problem areas, and follows-up to ensure
there is no relapse. The information
obtained from assessing in detail the exact
steps taken to deliver care to patients is used
to improve, correct and change problems
and standardize functioning.
Microsystems-focused thinking is a decep-
tively simple concept that builds the foun-
dation for wide-spread system change and
improvement. It makes the mandate to cre-
ate efficient, highly reliable systems doable
by bringing change down to the personal
level. Unlike toolkits and patented products
found in the marketplace, microsystems is a
conceptual framework. Dr. Luan explains
that its implementation requires only
curiosity, dedication and a willingness to
look at ourselves and what we do every day
with a new set of lenses. As powerful as it is
simple, focusing on the microsystem facili-
tates positive change one step at a time,
beginning with each patient, each one of us,
and each task we perform in our efforts to
provide care.
PATIENT FALL PREVENTION UPDATE
More Details in Summer Newsletter,
Focused Review
The Eighth Annual Patient Falls Conference,
titled “Transforming Fall Prevention Prac-
tices”, was held April 15-18, 2007 in Clear-
water, Florida.
The DoD Patient Safety Center (PSC) will
summarize findings identified during the con-
ference in the next Newsletter. In mid July
2007, the PSC will publish a Focused Review
featuring an analysis of patient falls within
DoD and strategies for enhancing existing
patient fall prevention programs at the MTF
level. This information will enable facilities to
ably comply with the 2007 National Patient
Safety Goal 9B—Implement a fall reduction
program—including an evaluation of the
effectiveness of the program.
THE TRIPLER
ARMY MEDICAL
CENTER RAPID
RESPONSE TEAM
A Force for Improved Communication
and Patient Safety
Eric A. Crawley MD, LTC, MC, USA
Chief, Critical Care,Tripler Army Medical Center
Tripler Army Medical Center (TAMC) imple-
mented a fully funded and executed Rapid
Response Team (RRT) on November 1, 2006.
The team has been very well received and is
widely perceived as being of great value
across the institution. Executed as a Pilot
Study sponsored by MEDCOM Patient Safe-
ty, the TAMC RRT demonstrates that RRT's
are feasible, effective and relevant in the Mil-
itary Health System (MHS). Dr. Eric Craw-
ley, Chief of Critical Care at TAMC believes
the RRT has been a force for positive change
in the inpatient venues and has contributed
to a safer and more collaborative environ-
ment. In this article Dr. Crawley shares the
concepts behind and the motivations
prompting the creation of the RRT, interim
results and several illustrative cases.
Rationale and Potential Benefits of RRT's
The Tripler RRT model makes a distinction
between the RRT and the Code Blue Team. It is
important to understand the differences
between the teams. The Code Blue team con-
tinues to be the team which brings the equip-
ment and personnel necessary to mount the
robust ACLS response required when a patient
is in extremis. The RRT response has a much
smaller footprint and is more cognitive and
measured in nature. As the response is less dra-
matic than the Code Blue, staff are often less
hesitant to activate the RRT versus the Code
Blue Team. A premium is placed on assess-
ment, interpersonal and communication skills
among responders. For the above reasons, the
RRT is not intended for patients who are in
need of immediate lifesaving interventions.
The main benefit of the TAMC RRT is that it
institutionalizes a means of identifying and
responding to patients who are manifesting
early signs of clinical deterioration or symp-
toms of concern. This comes from the recog-
nition that in retrospect most cardiac arrests
were predictable based on vital signs and other
clinical findings present in the hours leading
up to the arrest. It is generally accepted that
interventions applied earlier in the course of a
patient's decline might avert cardiac arrests or
organ system failure. The unfortunate reality is
that preventable morbidity and mortality con-
tinues to occur. This could potentially be
averted if staff were better at identifying prob-
lems and intervening at an earlier point.
Preventable adverse patient outcomes attrib-
utable to human factors are often related to
one or more of the following elements: com-
munication failure, deficits in knowledge,
and/or skill or lapses in attention. The RRT
concept can potentially mitigate each of
these human factors. As successful RRT
implementation is reliant on a commitment
to education of hospital staff and RRT
responders, it is a means for conveying con-
cepts which enhance communication among
members of the health care team.
RRT training is an opportunity to reinforce
communication tools such as SBAR (Situation,
Background, Assessment, Recommendation)
and tackle barriers to effective communication
which arise from differences in rank, position
and experience. In addition to enhancing com-
munication, the pre-implementation training
seeks to provide staff members with the cogni-
tive skills necessary to identify and respond to
patients with subtle findings suggesting clinical
deterioration. During the RRT response, the
more experienced RRT nurses often function
as teachers and mentors providing much need-
ed clinical expertise. This reassures the junior
nurses that help is readily available if they find
themselves outside their clinical comfort zone.
Training not only emphasizes the RRT acti-
vation triggers but also the institutional
expectation that an RRT call is mandatory
when a trigger is met. The RRT in effect
becomes a forcing function that requires
staff members to address findings of concern
and when activated prompts the health care
team to focus their attention and review the
diagnostic and treatment plan in more detail
than perhaps they might have otherwise.
To dispel concerns that the RRT will make
unilateral medical decisions or make value
judgments regarding quality of prior care, it
is essential that the role of the RRT is well
defined. Tripler has placed great emphasis on
the collaborative nature of the RRT. The RRT
does not supplant or usurp the primary team
but responds to assist the primary team with
assessment, stabilization, communication
and if necessary the transfer of their patient
Photo of Rapid Response Team in action from
Tripler RRT Family Brochure. Brochure caption
reads: We hope you never need to use the
Rapid Response Team, however, Tripler Army
Medical Center is committed to providing pro-
grams for patient safety and quality care.
to a higher level of care. When the RRT is
called, the primary service must also be noti-
fied. The RRT works under the direction of
the primary service in support of that team's
treatment plan. This framework has been
well received by all clinical services.
Specifics of the TAMC RRT
The team is available twenty-four/seven to all
inpatients and outpatients. Although initially
envisioned as an inpatient resource it has
shown value in the outpatient clinics as well.
The team responds to a patient's bedside
within five to ten minutes of activation. It is
comprised of a Critical Care Nurse, and a Res-
piratory Therapist, with an on call Critical
Care physician functioning as the team con-
sultant. The team has some limited standing
orders, and the RRT nurse brings a device
allowing for point of care ABG testing. Each
response is documented in the inpatient
record and data is collected via an RRT log.
Caller surveys are distributed to grade each
response and patient follow ups are per-
formed six to eight hours post response.
The Call Criteria or activation triggers are
similar to those published in the literature,
with the exception of our selection of a more
sensitive tachypnea trigger. They are:
• RR < 8 or > 24
• HR < 40 or > 130
• Acute Change in Mental Status
• SpO2 < 90% with O2 Supplement
• SBP < 90 mmHg
• Staff Worried
• Family Concerned
PATIENT SAFETY SPRING 2007 7
TRIPLER RRT twenty-four hours of a call to make sure promising that team's autonomy. The
Continued from Page 7 their concerns have been addressed. enlistment of patient and families in team
activation sends a message to our benefici-
Since inception, the RRT has responded to Illustrative Cases aries that the institution is responsive and
one hundred thirty-four calls throughout Recently, a 35 year old woman admitted for that their concerns are taken seriously. The
the facility. The average has been twenty- abdominal pain developed respiratory dis- net effect of all of the above is to create an
seven calls per month which is in line with tress. The RRT was activated and a pre- environment where communication is
IHI call rate predictions of 10calls/100beds/ sumptive diagnosis of massive pulmonary enhanced, help is embraced and patient
month. Often, multiple triggers were met. embolism was made. The patient was rap- safety is maximized.
The most common trigger found in 68% of idly transferred to the ICU where after con-
calls was activation due to Staff Concern. firmation she received thrombolytic thera- While not a panacea it is our sincere belief
This seemingly vague and subjective trigger py with resolution of her respiratory dis- that when funded and executed appropri-
has been found to be very sensitive and tress. It is doubtful that the evaluation and ately with adequate staffing, the RRT con-
meaningful. The table below demonstrates transfer would have occurred as expedi- cept can significantly improve the quality
frequency of calls by trigger. tiously without the RRT. of inpatient care provided in the MHS.
This author believes it is time for the MHS
A woman in her early 20's was preparing to to embrace that which is widely viewed as
70
be discharged from an ambulatory surgical essential in the civilian healthcare sector.
60
center. She appeared pale and diaphoretic
50
and became orthostatic. She and her hus- Comments, questions and requests for RRT
40
band were highly concerned. The surgical implementation and training aids can be
30
team was unavailable and the RRT was directed to Dr. Crawley at (808) 433-2297
20
called. The RRT evaluated the patient and or Eric.crawley@us.army.mil.
10 conferred with the surgical team. It was
0 very reassuring to the patient and husband
Staff Concern

SaO2 < 90%

Acute Mental Status

SBP < 90

RR > 24

that their concerns were taken seriously.

The patient left later that day with PATIENT SAFETY
improved confidence in the care the insti-
tution provided.
PROGRAM NEWSLETTER
Published quarterly by the Department of Defense
(DoD) Patient Safety Center to highlight the progress
A patient on inpatient psychiatry with of the DoD Patient Safety Program.
depression and anxiety developed increasing
A review of call dispositions reveals that the dyspnea which had been ascribed previous- DoD Patient Safety Program
majority (56%) of patients could be man- ly to anxiety based on prior negative evalua- Office of the Assistant Secretary
aged on their ward. Transfer to the ICU was tions. The psychiatry nurse was appropriate- of Defense (Health Affairs)
required in 25%, Stepdown Unit in 9%, ly concerned and activated the RRT. The
TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike
and ER in 5%. To date it does not appear patient was found to be in impending respi- Falls Church, Virginia 22041
that the RRT has adversely affected the ICU ratory failure from undiagnosed neuromus- 703-681-0064
Forward comments and suggestions to:
census. Currently there is insufficient data cular disease. This response averted what DoD Patient Safety Center
to comment on changes in Code Blue rates, would have most likely been a Code Blue on Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100
ICU length of stay or other objective out- a locked psychiatric ward. Silver Spring, Maryland 20910
Phone: 301-295-7242
comes primarily due to challenges in estab- Toll free: 1-800-863-3263
lishing historical baseline data, and the Summary DSN: 295-7242 • Fax: 301-295-7217
E-Mail: patientsafety@afip.osd.mil
brief interval since RRT implementation. The TAMC experience with the RRT has Website: https://patientsafety.satx.disa.mil
been uniformly positive. It is our belief E-Mail to editor: poetgen@aol.com

In the near future, Hospitalists will be that our staff are better able to recognize DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM
incorporated into the team. A Pediatric subtle findings leading to the earlier iden- COL Steve Grimes
RRT is being developed. We will be using tification of clinical deterioration and that DIRECTOR, PATIENT SAFETY CENTER
Geoffrey Rake, MD
automatic clinical alerts from the electron- when recognized, those staff now have a DIRECTOR, CENTER FOR EDUCATION
ic medical record system to help increase means of rapidly marshalling help. We AND RESEARCH IN PATIENT SAFETY
Eric S. Marks, MD
identification of patients meeting RRT believe that the RRT nurse in particular DIRECTOR, HEALTHCARE TEAM
trigger criteria. In recognition of the value brings expertise to the bedside in support COORDINATION PROGRAM
Ms. Heidi King
of patient and family concerns, effective of an increasingly junior and transient
SERVICE REPRESENTATIVES
June 1, 2007 a Family Brochure explaining nursing staff. The institutional expectation ARMY
the RRT will be given to all patients during that the RRT will be called when trigger LTC Robert Durkee
NAVY
admission. The brochure will explain when criteria are met places the responsibility on Ms. Carmen Birk
AIR FORCE
and how a patient or family member can the staff member to seek help. The collab- Lt Col Kathryn Robinson
contact the RRT. The RRT will follow up orative essence of the team provides assis- PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
Phyllis M. Oetgen, JD, MSW
with patients and family members within tance to the primary team without com-

8 SPRING 2007 PATIENT SAFETY