INSIDE: Disclosure Issues and Guidelines Page 4
Patient
Safety
A quarterly newsletter to assist DoD hospitals with improving patient safety
DoD Patient Safety
Program Begins Rollout
107 Attendees trained from 25 Facilities
I n August, 2001 DoD began to rollout the
Patient Safety Program training to regis-
trants from military treatment facilities in the
Mid-Atlantic region. Back-to-back training
sessions were held at the Uniformed Services
University of the Health Sciences (USUHS) in
Bethesda, Maryland July 31 thru August 3. A
third training session was offered at the
Chesapeake Conference Center in
Chesapeake, Virginia August 14 thru 16. A
total of 107 personnel from twenty-five facili-
ties were trained. Although the events of
September 11th necessitated the cancellation
of additional sessions in 2001, training work-
shops have already been scheduled for 2002.
Patient safety teams from the MTF’s,
including key opinion leaders and patient
safety champions, are the target audience for
the training workshops. The goals of the ses-
sions are to improve clinical practice and
enable participants to perform systematic
Root Cause Analysis in order to determine
causes and contributing factors associated
with medical errors and to reduce the poten-
tial for future errors. A certificate of atten-
dance is awarded to all attendees, and CME
and CEU credit is given.
The three-day training schedule includes
a full agenda that combines lectures with
small group breakout sessions that encourage
hands on application of concepts. Day 1 pro-
FALL 2001
FALL 20011
Page 2 Joint Commission Standards
Page 3 Patient Safety In Action
Page 3 Calendar
Page 4 Legal Corner
What’s New!
...DoD PATIENT SAFETY
Happenings
vides an overview of patient safety, beginning
with a spirited keynote address that details the
evolution of the current system-focused
T he DoD PATIENT SAFETY INSTRUCTION is now
officially on the web. It has a publication date of
August 16. You can access the Instruction at:
approach to patient safety, and a presentation
http//www.dtic.mil/whs/directives/ Click the link for
outlining the DoD patient safety program. Day
Instructions - the Patient Safety Instruction is 6025.17.
2 is devoted to understanding the tools used
The DoD PATIENT SAFETY CENTER at AFIP has
in the program - the Safety Assessment Code
enhanced its web accessibility for your convenience.
and Root Cause Analysis process and form.
The Center has a shorter URL: www.afip.org/PSC. In
Breakout sessions give participants the
addition, the home page of the AFIP website, reached at
opportunity to work through their own root
www.afip.org, now features a pop-up window, with a direct
cause analysis, based on a video simulated
link to the Patient Safety Center front page. As always, the
staged sentinel event. On Day 3 issues related
web page contains links to the Patient Safety Newsletter,
to implementation of the patient safety pro-
as well as on-line registration for up-coming training
gram are reviewed. In addition to a detailed
sessions.
implementation discussion, participants
The DoD Patient Safety Program has become a liai-
receive guidelines on disclosing errors to
son member of the LEAPFROG GROUP – an organization
patients and their families, and are instructed
set up by the Business Roundtable to make major
on how and when to report data to the Patient
improvements in patient safety. Leapfrog has identified
Safety Registry at the Armed Forces Institute
three “leaps” which it believes, if implemented by hospi-
Pathology.
tals, will improve patient safety: computerized physician
Upcoming training sessions will be held
order entry, evidence-based hospital referrals, and ICU
in San Antonio, San Diego, Florida and the
physician staffing. Leapfrog intends to mobilize employer
Midwest to facilitate convenient access for all
purchasing strategies to support hospitals that adopt these
the services. For dates and locations see the
suggested safety policies. DoD will participate in a nation-
Conference Calendar inside this Newsletter.
wide Leapfrog survey designed to gather information from
Registration information is posted on the
hospitals about their practices on the three Leapfrog
Patient Safety website. These training sessions
parameters. Participation with the Leapfrog Group repre-
are designed to provide MTF’s with the
sents a beneficial collaboration with private sector safety
knowledge and resources necessary to imple-
initiatives.
ment the DoD Patient Safety Program.
Please make plans now to attend a workshop
in 2002.
Medteams J. Jarrett Clinton, Acting Assistant Secretary of
Defense for Health Affairs, and Dr. James Sears, Patient Safety Links
INTERESTING RESOURCES FOR YOU
And Patient Executive Director, TRICARE Management
Activity, provided an overview of the military
TO EXPLORE

Safety health system. The MedTeams program was

included in their outline of the new initiatives
CROSSING THE QUALITY CHASAM
Second and final report of the Committee
on the Quality of Healthcare in America,

The National Defense being implemented to ensure patient safety.

The MedTeams system delivers aviation-
Institute of Medicine
FOCUS: Design of health care delivery
system to innovate and improve care

Authorization Act man- based teamwork training to health care

providers. Training addresses the formation of
For information: access www.nap.edu

dates MedTeams inclu- teams, teamwork behaviors and operational
reinforcement to promote the effective delivery
sion in DoD health care of care. To date, MedTeams has been imple-
mented and evaluated in nine hospital emer-
operations. gency departments nationwide, including
“BEYOND BLAME”
A powerful video which focuses on the
systemic causes of medical error.
SPECIAL INTEREST: This is an excellent
teaching tool.
For information: 1-800-350-0100…$10.00
donation requested

LEAPFROG GROUP:
Madigan Army Medical Center. Research and www.leapfroggroup.org

T he National Defense Authorization Act of

2001 specified that the MedTeams train-
ing program be integrated into all DoD health
care operations. To execute this mandate, the
Act requires the establishment of two Centers
for Excellence devoted to the development and
sustainment of the program. It calls for the
program to be deployed to all fixed and combat
casualty care organizations at the rate of not
less than 10 per year, and for the program to
expand from emergency department care to all
major medical specialties at the rate of one spe-
cialty per year. Finally, the Act authorizes con-
tinued research and development to improve
teamwork in health care.
In Congressional testimony last March, Dr.
development is currently underway to extend
the MedTeams system to the labor and delivery
arena.
Most MTFs have not yet had experience
with the MedTeams program. However, begin-
ning in 2002, MedTeams will train personnel
from ten military facilities who will be responsi-
ble for implementation of the program in their
emergency departments. In conformance with
the requirements of the law, each year ten more
MTFs will receive training, and the program will
expand beyond the emergency department to
other high risk, high stress hospital venues. As
this implementation phase begins, feedback will
be solicited and shared with our readers.
Mission: to initiate breakthroughs in the
safety and quality of healthcare in the U.S.
SPECIAL INTEREST: see web based hospi-
tal survey and results
PATIENT SAFETY LEADERSHIP FELLOWSHIP
www.healthforum.com/HFEducation/asp/
Fellowship.asp
Fellowship program focused on ways to
enhance patient safety. Sponsored by
American Hospital Association's Health
Forum and National Patient Safety Forum
For more information call: Duffy Newman
at 415-248-8405
Timely links on disaster readiness and
bioterrorism:
AMERICAN HOSPITAL ASSOCIATION DISAS-
TER READINESS RESOURCES:
www.aha.org/Emergency/Readiness/
Readiness Index/asp
AHA new disaster readiness guidelines,
issued in the wake of the Sept. 11th
attack. AHA will continue to study
responses and provide updates on effec-
tive disaster planning.

CDC Morbidity and Mortality Weekly

improving the safety of patient care. Effective July
Joint 2001 JCAHO began requiring health care organi-
Report
www.cdc.gov/mmwr/
Mission: make public weekly report to

Commission zations to comply with Patient Safety Standards.

The standards, according to JCAHO President Dr.
CDC from state health departments
SPECIAL INTEREST: see section entitled
“Information about Anthrax and

Patient Safety Dennis O’Leary, are intended to help create a

culture of safety in hospitals.
Bioterrorism” for up to date information

National Guidelines Clearinghouse

Standards The new patient safety standards that may

By: COL Judy L. Powers,
MEDCOM Patient Safety
Program Manager
T he November 1999 release of the IOM
report, “To Err is Human, Building a
Safer Health System”, focused attention on the
importance of effective strategies to reduce
patient harm. The Joint Commission (JCAHO)
has been a national leader in this effort, with a
formal Sentinel Event policy in place since 1995
and a recent rededication of its mission to
www.guideline.gov
Mission: a public resource for evidence-
based clinical practice guidelines spon-
have the most impact on organizational compli-
ance require health care leaders to facilitate a
sored by AHRQ
SPECIAL INTEREST: links to CDC's bioter-
rorism website
“culture of safety”. Organization leaders should
note the following standards, which they may find
especially challenging, relating to leadership,
improvement, rather than assessing or assigning
blame;
improving organizational performance, patient
PI 3.1, focuses on increasing reporting by
rights and human resources:
LD.5.2, requires leaders to ensure that an ongo-
ing, proactive program for identifying risks to
addressing staff’s willingness to report errors and
mandating solicitation of staff opinions regarding
the reporting process;
patient safety and reducing errors is defined and
RI 1.2.2, requires that patients and, when appro-
implemented;
priate, their families be informed about the out-
LD 5.3, specifies that the focus of patient safety
comes of care, including unanticipated out-
standards related to reporting is on identification
comes;
of processes and systems that will lead to
HR 4, mandates an orientation process that

2
provides initial job training and information and
assesses staff’ ability to fulfill responsibilities,
especially job-related aspects of patient safety;
HR 4.2, requires ongoing inservice and other
education and training to maintain and
improve staff competence and support an inter-
disciplinary approach to patient care, including
team training.
What can you do to facilitate successful
implementation and MTF compliance with the
JCAHO standards? No matter what position or
level in the organization assigned, each and every
staff member can:
a. Champion patient safety as a top organization
or clinic priority
b. Foster a culture of safety by reporting all near
miss and/or actual medical errors
c. Encourage all patients or family members to
immediately notify staff of any patient safety
concerns
d. Review the JCAHO Sentinel Alerts to increase
your knowledge
e. Share and implement strategies to prevent
occurrence in your MTF
COL Powers can be contacted at: DSN 471-6622;
CIV 210-221-6622;
email: judith.powers@amedd.army.mil.
A Power Point Briefing on the JC 2001 PS Standards is
available for MTF use on the Army Patient Safety Web
Page at http://www.cs.amedd.army.mil/qmo. For more
information contact the Joint Commission web site at:
www.jcaho.org.
Patient Safety
in Action
Experiences and
general. According to the Institute for Safe
Medication Practices, studies have shown that up
to 10 percent of medication dosages dispensed
in hospitals are given in error.
With this in mind, MTF’s should pay special
attention to medication dispensing and errors
that can be associated with medication
dosage, timing and identification. In both of
the RCA’s submitted during the pilot study, larger
than appropriate doses of medication were
administered. Although the factual situations
were dissimilar, review of contributing factors
identified poor communication, inadequate train-
ing and inconsistent enforcement of hospital
policies in each case. Action plans focused on
clarifying and enforcing policies and on training
a cross-section of professional staff, including
pharmacists, nurses and physicians. These expe-
riences from the pilot study underscore the inter-
related causes of medication errors, and they are
affirmed by outside experiences and authorities
as well.
This summer, incorrect dosages of the drug
Coumadin at St. Agnes Hospital in Philadelphia
were directly related to the deaths of two
patients. The fatal errors were due to laboratory
miscalculations involving the prothrombin test
necessary to check the patients’ rate of clotting.
Although it is tempting to dismiss these as
unique, related to the hospital’s use of a new
reagent, and thus unlikely to occur elsewhere,
the state health agency cited numerous deficien-
cies in the system of ordering, using and evaluat-
ing the reagent, citing small errors that added
up. This case is a compelling example of the
chain of errors involving many people and parts
of a system that underlies every event.
to recognize that medication errors are among
the most common experienced in the hospital
setting. They can originate in any number of
places and with any one of many health care
providers. Clear policies, communication and
ongoing monitoring of compliance are all neces-
sary elements in sustaining a system that reduces
medication errors. Resources such as JACHO
Alerts and the ISMP web site should be routinely
accessed for general information and practice
suggestions. As the DOD Patient Safety training
proceeds, and reporting becomes more wide-
spread throughout the military healthcare system,
the shared experience of the MTFs will become a
source of additional valuable lessons and strategy
interventions.
Conference
Calendar
DOD PATIENT SAFETY PROGRAM
TRAINING
1/8 – 1/10/02
SAN ANTONIO, TEXAS
1/9 – 1/11/02
SAN ANTONIO, TEXAS
2/12 – 2/14/02
SAN DIEGO, CALIFORNIA
2/13 – 2/15/02
SAN DIEGO, CALIFORNIA
4/2 – 4/4/02
ORLANDO OR JACKSONVILLE, FLORIDA

Suggestions from A September 2001 Sentinel Event Alert from

JCAHO calls attention to the need to be aware of
4/3 –4/5/02
ORLANDO OR JACKSONVILLE, FLORIDA
the field the medication errors related to potentially dan-
4/30 – 5/2/02
gerous abbreviations and dose expressions. The
MEDICATION ERRORS Alert singles out as especially problematic abbre-
MIDWEST – EXACT LOCATION TO BE
DETERMINED
viations that include “U” for “units” and “ug” for

T he DoD Patient Safety Program is a new

program, and reporting from the first
MTFs trained is just beginning. To date, there is
“micrograms”, as well as the use of trailing zeros
(2.0 vs 2) and the use of a leading decimal point
5/1 – 5/3/02
MIDWEST – EXACT LOCATION TO BE
DETERMINED
without a leading zero (.2 instead of 0.2). Risk
little information available on medication errors
reduction strategies are suggested, and range
in MTFs beyond that reported during the pilot 8/6 – 8/8/02
from increased use of computerized order entry
study. A review of the pilot data reveals that USUHS, BETHESDA, MARYLAND
systems to more cost efficient options including
medication errors were a significant percentage
developing a list of unacceptable abbreviations 8/7 – 8/9/02
of all near misses and adverse events, and were
and a policy to ensure that medical staff refer to USUHS, BETHESDA, MARYLAND
the cause of two of the six root cause analyses
the list and comply, as well as double checking
received. The prevalence of medication errrs in
unacceptable abbreviations if used. To confirm training dates and register
the pilot is consistent with medical experience in on-line access: www.afip.org/PSC
For practitioners in the field, it is important

3
 providers should be honest, compas-
LEGAL
Corner
sionate and helpful and should not be
afraid to express sorrow at the out-
come. Balancing the need to disclose
in a timely fashion, providers should
consult with risk management, patient
safety and legal counsel prior to dis-
closure and should plan their conver-
sation with the patient so that infor-
mation is factual, objective and com-
plete. Disclosure should not include
speculation about the cause of the
outcome, nor acceptance or assess-
ments of blame.

The disclosure requirement is one

of the most complicated legal issues A Reminder About
associated with patient safety. The
DOD Instruction Sec. 4.1.1.7. requires Reporting Requirements
that patients be informed in cases of
serious medical errors which cause Those facilities that have attended the patient an event is reported.
unexpected harm; and JCAHO Standard safety training are reminded that they must
RI.1.2.2. mandates that patients be begin to send their Summary Report Forms Reports should be sent to the Patient Safety
informed about the outcomes of care, and Root Cause Analysis forms to the Patient Center at AFIP via e-mail at this address:
including unanticipated outcomes.
Safety Registry at the Armed Forces Institute of psc@afip.osd.mil. If a hard copy is sent, it
Practitioners often find it difficult to
Pathology. Military Treatment Facilities are should be addressed to the DoD Patient Safety
know just how and what to say in the
face of the emotional reactions that
expected to commence sending summary Center, Armed Forces Institute of Pathology,
typically surround medical mistakes. reports sixty days after the completion of 1335 East West Highway, Suite 6-100, Silver
Uncertainty about disclosing med- training, and monthly thereafter. Reports are Spring, Maryland 20910. Questions about
ical errors is something that health due to AFIP by the 15th day following the end details of the reporting requirements can be
care providers everywhere experience. of the month. Thus, facilities trained in answered by your patient safety service repre-
Recent interesting discussions about August should already have submitted a sum- sentatives or by contacting the Patient Safety
dilemmas faced by disclosure can be mary report for November and December Center at 1-800-863-3263.
found in: the British Medical Journal, 2000. RCA forms are due forty-five days after
“Medical Errors and Medical Culture”
(Vol. 322, 19 May 2001); Medical
Economics, “What to Say” (August 20,
2001); and Medical Student JAMA,
“Ethical Issues Involved in Disclosing
Medical Errors” (Vol. 286, Sept. 5,
2001). All of these articles under-
score that, while there is general
agreement that disclosure is appropri-
Patient
ate, how to disclose and how much to
disclose is still very much dependent
on the individual situation.
It is important to keep in mind
that disclosure of an unanticipated
Safety
Patient Safety is published by the Department of Defense (DoD) Patient Safety Center,
located at the Armed Forces Institute of Pathology (AFIP). This quarterly bulletin provides periodic updates
outcome or error is not disclosure of
on the progress of the Tri-Service Patient Safety Program at all military medical treatment facilities.
negligence. Disclosure is merely a
Please forward comments and suggestions to the editors at:
factual statement of outcome, and
does not offer an analysis of what
DoD Patient Safety Center
went wrong and whether the fault lies
Armed Forces Institute of Pathology
with human failures, system failures
1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
or a combination. A quality assurance Phone: 301-295-8115 Fax: 301-295-7217
review will generally follow disclosure E-mail: PSNewsletter@afip.osd.mil Website: to www.afip.org/Departments/PSC/index.html
and information or materials created
CHAIR, DoD PATIENT SAFETY WORKING GROUP: Capt. Frances Stewart, MC, USN
for quality assurance, as they are pro- SERVICE REPRESENTATIVES:
tected under 10 U.S.C. 1102 and may ARMY COL. Judith Powers, AN
not be released to the patient. NAVY Ms. Carmen Birk
AIR FORCE Ms. Sarah Tackett, CPHQ
It is difficult to find hard and fast PSC COORDINATOR: Richard L. Granville, MD, JD
guidelines regarding disclosure, PATIENT SAFETY BULLETIN EDITOR: Phyllis M. Oetgen, JD, MSW
because each case is unique.
However, in all disclosure situations,