THIS ISSUE: DoD Patient Safety Reporting System Update

SUMMER 2006 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

TRI-SERVICE SURVEY ON PATIENT SAFETY

OVERALL MILITARY HEALTH SYSTEM RESULTS
Survey History and Characteristics patient safety is not just a function of hav- November 10, 2004, http://www.ahrq.gov/
ing the best research findings available”, she news/press/ pr2004/hospcult2pr.htm).

T
he Tri-Service Survey on Patient explained in her introductory remarks.
Safety was conducted in late “There has to be an environment or culture Partnering with AHRQ from the incep-
2005/early 2006 across the Military that encourages health professionals to tion of the survey were Premier, Inc., the
Health System (MHS). Jointly sponsored share information about patient safety American Hospital Association, and the
by the Patient Safety Program and TRI- problems and actions that can be taken to Department of Defense. At the time of the
CARE Management Activity (TMA) the make care safer, and that also supports survey’s release, David Tornberg, M.D.,
survey is an anonymous, web-based initia- making any changes needed in how health M.P.H., Chief Medical Officer for DoD
tive designed to assess staff attitudes and care is delivered” (See Press Release, Continued on Page 2
beliefs about patient safety, medical error,
and event reporting in MHS facilities. Data
was collected from all MHS fixed facilities
worldwide, comprising sixty-eight (68)
hospitals, three hundred forty (340) outpa-
tient clinic/ambulatory care centers, and
seventy-six (76) dental clinics. A total of
62,548 Army, Navy and Air Force respon-
dents, including clinical staff, house staff,
non-clinical staff, active duty and reservist
military, civilian GS employees and con-
tractors, completed the survey.

The survey tool was developed and

pilot tested by Westat under contract to the
Agency for Healthcare Research and Quali-
ty (AHRQ) in 2004. It has been imple-
mented by dozens of private sector hospi-
tals and outpatient facilities across the
United States, and has proven both its reli-
ability and validity. AHRQ Director Car-
olyn M. Clancy, M.D., when introducing
the survey in November 2004, described its
rationale as an effort to measure organiza-
tional conditions that can lead to adverse "12 Areas of Patient Safety Culture" from the Tri-Service Survey on Patient Safety,
events and patient harm. “Improving Overall MHS Results, May 2006

SUMMER 2006

3 Survey Graphics
5 Patient Safety Booth
5 TeamSTEPPS Booth
TRI-SERVICE SURVEY
Continued from Page 1
MHS, TRICARE, explained: “The DoD
Patient Safety Program is dedicated to
improving patient safety in all military
health care settings through evaluating
processes and systems of health care delivery
in military treatment facilities. This survey
will help the DoD’s Military Health System
realize our mission of improving patient
safety by enabling open promotion and dis-
cussion regarding the identification of safety
issues specific to each unique environment
in our system” (See Press Release, November
10, 2004, http://www.ahrq.gov/news/press/
pr2004/hospcult2pr.htm).
Because staff members work day-in and
day-out delivering patient care, the survey
sought to collect their opinions about
patient safety issues, error, and event report-
ing in their facilities. The survey was
announced to staff by an e-mail from the
MTF Commander or Patient Safety Manag-
er. This initial notice was accompanied by a
memo of support from Dr. William Winken-
werder, Assistant Secretary of Defense for
Health Affairs, and a Service-specific support
memo. Staff were provided with a hyperlink
to the survey web site, and were reminded
multiple times to complete the survey. The
"Overall Patient Safety Grade" from the Tri-Service Survey on Patient Safety, Overall MHS
Results, May 2006.
2 SUMMER 2006 PATIENT SAFETY
majority of tri-service respondents had
direct patient contact and worked 40-59
hours per week. Most were military-active
duty. Half of all respondents worked in their
MHS facility from 1 to 5 years, with nearly
half (49%) assigned to their current work
area for the same amount of time.
The culture survey was conducted through-
out the MHS with four specific goals in mind:
• to improve the quality of healthcare services
and provide a safer care environment in all
MHS settings
• to understand the status of patient safety
culture in MHS facilities
• to raise staff awareness about patient safety
issues
• to use the results as a tool for forward
action planning and program evaluation
An added benefit of the survey was its
utility in meeting several Joint Commission
on Accreditation of Healthcare (JCAHO)
standards related to performance improve-
ment and leadership: collecting data on staff
opinions and perceptions; ensuring imple-
mentation of an integrated patient safety
program; setting performance improvement
priorities; allocating adequate resources for
assessing performance; and measuring and
assessing effectiveness of performance
improvement and safety improvement activities.
Patient Safety Culture Survey Results
Twelve general areas of patient safety cul-
ture were assessed in the survey: overall per-
ceptions of patient safety; frequency of
events reported; supervisor/manager expec-
tations and actions promoting patient safety;
organizational learning/continuous improve-
ment; teamwork within work areas; commu-
nication openness; feedback and communi-
cation about error; nonpunitive response to
error; staffing; management support for
patient safety; teamwork across work areas;
handoffs and transitions. Each area was
explored with three or four survey items, for
which respondents either “Agreed/Dis-
agreed” on a 5-point scale or indicated a 5-
point frequency response from “Never” to
“Always”. In addition, two single-item ques-
tions asked staff to indicate their work area’s
“grade” (from “A – Excellent” to “E – Fail-
ing”) on patient safety and the number of
event reports they had submitted over the
past twelve months.
There is no doubt, judging from the
overall response to the culture survey, that
patient safety is a familiar issue in MHS facil-
ities. Nine of the twelve survey areas received
a 50% or better positive response, with only
three areas falling below 50%. Most respon-
dents gave their work area either an “A-
Excellent” or a “B -Very Good” grade on the
single-item question asking for an over-all
patient safety grade.
In interpreting the survey results, the
patient safety culture areas with the highest
positive scores as rated by MHS staff were
deemed Patient Safety Strengths, while those
with the lowest positive scores were designat-
ed Areas for Improvement.
In addition to the general Patient Safety
“Grade”, Teamwork Within Work Areas,
Supervisor/Manager Expectations and
Actions Promoting Patient Safety, and Man-
agement Support for Patient Safety were con-
sidered strengths. Finding that manage-
ment support for patient safety is a recog-
nizable strength comes as a welcome affir-
mation that the patient safety is a priority
throughout the MHS. Responses to all sur-
vey items in this category were positive, with
respondents agreeing that management in
their facilities provides a work climate that
promotes patient safety, that actions of
management show that patient safety is a
Continued on Page 3
TRI-SERVICE SURVEY
Continued from Page 2
top priority, and that management is not
only interested in patient safety after an
adverse event happens.
Respondents indicated that the focus on
safety translates from the management level
to the supervisor/care-giver level in MHS
facilities. Supervisor/manager expectations
and actions were probed in survey items that
asked whether supervisors acknowledged jobs
done according to established patient safety
procedures, considered staff suggestions for
improving patient safety, showed low toler-
ance for shortcuts under pressure, and took
notice of repeated patient safety problems.
Uniformly high positive responses to these
questions indicate patient safety is promoted
by supervisors on the patient care level.
The highly positive reaction to questions
about Teamwork Within Work Areas suggest
that teamwork is recognized in MHS facili-
ties as a helpful patient safety strategy.
Respondents affirmed that “people support
one another”, that they “work as a team to get
the work done”, they “treat each other with
respect”, and “when one section…gets really
busy, others help out”.
Areas for Improvement, or those areas
surveyed which received the lowest positive
responses, included Staffing, Nonpunitive
Response to Error, Handoffs and Transitions,
and the single-item query on Number of
Events Reported. The survey report cau-
tions, however, that some areas with low
positive responses identified as areas for
improvement contained large percentages of
staff who neither agreed nor disagreed. This
rendered their responses neutral, unsure or
“less than positive”. Although these were
included as negative responses, in fact, they
do not actually indicate a negative percep-
tion. It should be noted, as well, that the
Patient Safety Program introduced its
Handoff Toolkit in December 2005, too
close to the survey collection time for its
impact to be measured.
Next Steps
Department of Defense Survey Follow-up
Within the Department of Defense, the
Patient Safety Culture Survey represents one
of the three major initiatives undertaken
"Action Planning for Improvement" from Tri-Service Survey on Patient Safety, Overall
MHS Results, May 2006
over the last two years by the DoD Patient
Safety Program. With data collection now
completed, information derived from the
Survey will be used throughout the MHS to
help develop next step strategies to improve
patient safety. On an enterprise level, the
MHS will be reviewing survey results to
determine objective criteria for what are to
be considered strengths and areas for
improvement. Individual services, facilities
and regions will receive feedback on survey
results – both on the aggregate and individ-
ual level. Following MHS wide communica-
tion and discussion of survey data, focused
action plans will be developed to address
patient safety efforts from the MHS level
down through specific services to individual
work places. The long-term value of the
Patient Safety Culture Survey will come from
Action Planning for Improvement -- trans-
forming insights derived from the survey
data into action plans, and action plans into
measurable improvements in patient safety
across the MHS environment.
AHRQ Survey Follow-up
National Database for Participating Hospitals
Entirely separate from the Department of
Defense follow-up are the next steps planned
by the AHRQ. On a national level, hospitals
conducting the Patient Safety Culture Survey
have been invited to register with the AHRQ
Survey Database. This national data reposi-
tory is currently being established in
response to interest from hospitals using the
survey, who have indicated a desire to com-
pare their results with those of other hospi-
tals in support of patient safety culture
improvement efforts. A decision by the
Department of Defense about participation
in the database is pending at this time.
Data submission was accepted during
May and June of this year. From July to
October AHRQ will be processing the data
received. As part of the database project,
AHRQ plans to produce average scores and
percentiles on the survey items and compos-
ites to help hospitals assess their own results.
Aggregate (not individual) hospital-level
averages and percentiles will be available free
to the public in a Chartbook to be posted on
the AHRQ web site sometime after October
2006. Currently, preliminary benchmarks are
available on the AHRQ web site to allow hos-
pitals to compare their survey results against
the results from twenty hospitals that partic-
ipated in a pilot test of the Survey in 2003.
For more information on this national
effort, see the AHRQ website at
http://www.ahrq.gov/qual/hospculture/
overview.htm.
PATIENT SAFETY SUMMER 2006 3
 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting
PATIENT SAFETY
REPORTING SYSTEM
UPDATE
Patient Safety Center and Services
Assist PSP As It Moves to Enterprise-
Wide System
O
n July 5, 2005, Military Medical
Technology Online Edition pub-
lished a Patient Safety Update (Vol-
ume: 9 Issue: 4). (http://www.military-medical-
technology.com/article.cfm?DocID=1022)
As part of that update, the following history
of the patient safety program and reporting
requirements was provided:
On the heels of the 1999 IOM report, the
Floyd D. Spence National Defense Authoriza-
tion Act of Fiscal Year 2001 established the
congressional mandate for DoD to establish a
"centralized process for reporting, compilation,
and analysis of errors in the provision of health
care under the defense health program that
endanger patients beyond the normal risks."
The Patient Safety Center (PSC) was estab-
lished as the repository for reporting medical
errors from the Military Health System (MHS).
For the past two years, a tri-service patient
safety requirements group has been refining
the elements of an enterprise-wide, Web-based
event reporting system that will be deployed
throughout the MHS beginning in 2006. The
Patient Safety Reporting (PSR) system is a key
feature of the DoD patient safety portfolio,
which contains a robust mix of technology,
training, and evidence-based programs.
…The PSR will provide standardized event
and near-miss capture and reporting of patient
safety events at MTFs throughout DoD. It will
also provide full event analysis capabilities and
reporting of appropriate information on
patient safety within the MHS to the Patient
Safety Center and to authorized external agen-
cies. Eventual integration of the PSR capability
with the DoD MEDMARX medication event
reporting system and a root cause analysis
capability are planned. Currently, the PSR sys-
tem is undergoing a “proof of concept” at three
MTFs. A proof of concept is an extension of
4 SUMMER 2006 PATIENT SAFETY
concept exploration, testing selected commer-
cial off-the-shelf products in the MHS to deter-
mine the product’s ability to successfully incor-
porate itself into different hospital settings, as
well as provide useful reporting to the different
levels of command. This is the first time this
concept is being tested in the MHS.
Almost exactly one year later, the Patient
Safety Reporting System is moving closer to
completion and deployment. The following
update outlines the progress that has been
made over the last year, and describes the
limited deployment and testing that will be
taking place in the late summer, early fall of
this year. The Patient Safety Newsletter will
continue to provide updates as the Report-
ing System is refined and evolves toward
final deployment.
Patient Safety Reporting System Update
The Department of Defense is continuing
its procurement of an enterprise-wide Patient
Safety Reporting system (PSR). A critical part
of that process involved refining functional
requirements with the Service’s involvement.
Five separate Joint Application Configuration
(JAC) sessions were held in Tysons Corner,
Virginia during the last year. Representatives
from the nine military treatment facilities
(MTFs) participating in the limited deploy-
ment participated in the sessions. During
these JAC sessions the participants completed
a thorough review of the functional require-
ments, completed business rules, received
hands-on demonstrations of the PSR applica-
tion, and began discussions related to imple-
mentation and training activities.
The next phase for the PSR program
consists of laboratory testing of the applica-
tion. System Integration Testing (SIT) began
22 June with a SIT Test Readiness Review
when the vendor presented the application
to the government for testing. Testing will
be accomplished by an independent valida-
tion and verification (IV&V) organization
which will test all required functionality,
load test the application, and insure that
systems administration features are fully
functional. SIT testing is scheduled to be
completed in August.
The MTFs participating in the limited
deployment, Service headquarters staff, and
the Patient Safety Center (PSC) will then get
their hands on the PSR, again in a controlled
laboratory environment for System Qualifi-
cation Testing (SQT). The testers will consist
of PSC staff, patient safety staff from the
MTFs participating in the limited deploy-
ment, and Service Headquarters (BUMED,
AFMOA, and MEDCOM) staff. SQT testing
is scheduled to last 5 days and is tentatively
scheduled for Fall 2006.
SQT participants will not only validate
that the functional requirements have been
met, but will also evaluate the vendor’s train-
ing materials and training methods. They
will also evaluate the ease of use of the PSR
whether the system provides value added in
the process of collecting and managing event
reporting. As part of the contract an e-learn-
ing module has been developed for training
reporters at the MTF. This module will reside
on the MHS Learn web-site and will also be
evaluated by the SQT participants.
The following MTFs are participating in
the PSR limited deployment:
Army
• Brooke AMC, San Antonio, TX
• Martin Army Hospital, Ft. Benning, GA
• Kimbrough Ambulatory Health Center,
Ft. Meade, MD
Navy
• National Naval Medical Center,
Bethesda, MD
• Naval Hospital Camp Lejeune, NC
• Naval Hospital Pensacola, FL
Air Force
• 59th Medical Wing, Wilford Hall
Medical Center
• 355th Medical Group, Davis Monthan AFB
• 48th Medical Group, Lakenheath AFB,
England
 PATIENT SAFETY IN ACTION
Experiences and Suggestions From the Field

DoD PATIENT SAFETY PROGRAM ESTABLISHES

NATIONAL PRESENCE
Collaborations and Booths Contribute to Expanding Role in Patient Safety Efforts
facilities encircled by the three integrated
resources the Program provides – the Center
for Education and Research, the Patient Safe-
ty Center, and the Healthcare Team Coordi-
nation Program. PSP personnel exhibited
the booth and shared PSP accomplishments
and activities at the National Patient Safety
Foundation Patient Safety Congress in May,
and at the Institute for Healthcare Improve-
ment (IHI) 2nd Annual Summit on
Redesigning Hospital Care in June.

Just this summer, the PSP has finalized its

TeamSTEPPS exhibition booth. This state-
of-the-art presentation booth combines still
graphics with a video screen, so that a con-
tinuous TeamSTEPPS review can be present-
ed. The TeamSTEPPS booth was introduced
at the ARHQ conference in June, and it will
MHS Patient Safety Program Booth become a companion piece to the DoD PSP
booth at future meetings. The PSP plans to

T
his year has been a busy one for the TeamSTEPPS is being actively deployed display both resources at the upcoming
DoD Patient Safety Program (PSP). throughout the Department of Defense, AMSUS (Society of the Federal Health Agen-
Having identified three major initia- AHRQ is spearheading its introduction this cies) meeting in November, and at the IHI
tives – the Patient Safety Culture Survey, summer to the civilian sector. 18th Annual National Forum in December.
TeamSTEPPS, and the Patient Safety Report-
ing System – the PSP has seen significant As its involvement
accomplishments in all three areas. Results with national patient
of the Patient Safety Survey can be found on safety efforts increases,
page 1 of this Newsletter. A status report on the PSP has sought to
the Reporting System is provided on page 4 by become a more visible
the Patient Safety Center. A full description of presence at civilian
the TeamSTEPPS initiative was featured in the patient safety forums.
Spring newsletter. In addition to their sub- To this end, the PSP
stantive importance, each of these programs has developed three
has allowed the PSP to build on its mandate of portable presentation
collaboration with outside agencies. booths. Two of these
booths are a graphic
One of the original partners with the representation of the
Agency for Healthcare Research and Quality DoD Patient Safety
(AHRQ) in releasing the Hospital Survey on Program. The newest
Patient Safety Culture, the DoD PSP contin- booth, pictured above,
ues to collaborate with AHRQ on the devel- depicts the unique
opment and dissemination of TeamSTEPPS. nature of the DoD
The PSP is a nationally recognized leader in Patient Safety Pro-
healthcare team coordination, having gram, with its individ-
trained more of its institutions in teamwork ual service units and
than any other system in the world. As military treatment Healthcare Team Coordination Program TeamSTEPPS Booth

PATIENT SAFETY SUMMER 2006 5

 PATIENT SAFETY LINKS
Interesting Resources To Explore
This issue, Patient Safety Links
focuses on larger-scale initiatives
that draw attention to, or assist in,
overall organizational change. The
good news from IHI first…
Institute for Healthcare Improvement
http://www.ihi.org
IHI announced on June 14th that the
100,000 Lives Campaign has exceeded
its goals. To date, 3,000 hospitals have
enrolled, and have collectively prevent-
ed an estimated 122,300 deaths.
…but, work still remains…
The National Academies Press
h t t p : / / n e w to n . n a p. e d u / c a t a l o g /
11623.html
Institute of Medicine
Preventing Medication Errors: Quality
Chasm Series
Committee on Identifying and Pre-
venting Medication Errors, Aspden P,
Wolcott J, Bootman JL, Cronenwett
LR, eds. Washington, DC: The Nation-
al Academies Press; 2007.
A major report by the IOM suggesting
that, despite recent efforts, medication
errors remain common. The report
emphasizes actions that both health
care systems and patients can take to
reduce medication errors.
Journal of the American Medical Asso-
ciation
http://www.jama.com
“Tracking Progress in Patient Safety”:
An Elusive Target
August 9, 2006,Vol 296, No. 6, pp. 696-699
Respected patient safety authorities
Peter Pronovost, MD, Marlene Miller,
MD and Robert Wachter, MD, acknowl-
edge the difficulty in adequately meas-
uring safety efforts to date, and propose
a potential method by which hospitals
can measure progress in patient safety.
Health Services Research
http://www.blackwell-synergy.com/doi/
abs/10.1111/j.1475-6773.2006. 00565.x
Aug. 2006, Vol. 41, Issue 4p2,
6 SUMMER 2006 PATIENT SAFETY
pp. 1555-1575
“Sensemaking of Patient Safety Risks
and Hazards”
Battles JB, Dixon NM, Borotkanics RJ,
Rabin-Fastmen, B, Kaplan HS
The authors discuss “sensemaking”: a
mechanism to better understand and
mitigate the factors that contribute to
medical errors. This conceptual
framework employs both RCA and
FMEA analyses, and offers a high-level,
integrated process to improve patient
safety efforts within an organization.
Massachusetts Coalition for the Pre-
vention of Medication Errors
http://www.macoalition.org/documents/
respondingToAdverseEvents.pdf
“When Things Go Wrong: Respond-
ing To Adverse Events”
This consensus statement of the Har-
vard Hospitals summarizes best prac-
tices to follow when a patient suffers
injury from medical treatment. A free
pdf version of the report is available on
the referenced website.
Pennsylvania Patient Safety Report-
ing System
http://www.psa.state.pa.us/psa/lib/psa/
verbal_orders_toolkit/verbal_orders_
article.pdf
“Patient Safety Advisory: Improving the
Safety of Telephone or Verbal Orders”
Article includes examples, safe practices,
a checklist for policies and procedures
and references a verbal orders toolkit.
The New England Journal of Medicine
http://www.nejm.org
July 13, 2006, Vol 355, No 3, pp. 121-123
“System Failure versus Personal
Accountability – The Case for Clean
Hands”
The author argues that, while the sys-
tems approach changes are at the root
of improving patient safety, we need to
strike a balance between organization-
al change and personal accountability.
In the case of clean hands, the focus
should be on individual caregivers reli-
ably practicing simple hand hygiene.
PATIENT SAFETY
PROGRAM NEWSLETTER
Published quarterly by the Department of Defense
(DoD) Patient Safety Center to highlight the progress
of the DoD Patient Safety Program.
DoD Patient Safety Program
Office of the Assistant Secretary
of Defense (Health Affairs)
TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike
Falls Church, Virginia 22041
703-681-0064
Forward comments and suggestions to:
DoD Patient Safety Center
Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100
Silver Spring, Maryland 20910
Phone: 301-295-7242
Toll free: 1-800-863-3263
DSN: 295-7242 • Fax: 301-295-7217
E-Mail: patientsafety@afip.osd.mil
Website: https://patientsafety.satx.disa.mil
E-Mail to editor: poetgen@aol.com
DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM
COL Steve Grimes
DIRECTOR, PATIENT SAFETY CENTER
Geoffrey Rake, MD
DIRECTOR, CENTER FOR EDUCATION
AND RESEARCH IN PATIENT SAFETY
Eric S. Marks, MD
DIRECTOR, HEALTHCARE TEAM
COORDINATION PROGRAM
Ms. Heidi King
SERVICE REPRESENTATIVES
ARMY
MAJ(P) Robert Durkee
NAVY
Ms. Carmen Birk
AIR FORCE
Lt Col Kathryn Robinson
PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
Phyllis M. Oetgen, JD, MS
DoD PATIENT SAFETY WEBSITE
The DoD Patient Safety Program now sponsors two
websites to enhance communication of Program
details and patient safety information.
The official DoD Patient Safety Website is accessible
at: https://patientsafety.satx.disa.mil. This is the
source of the most current information about the
Patient Safety Program. It provides information on
the structure and initiatives of the Program, its vari-
ous components and related activities. The site
includes a calendar of events, a link for patient safety
training registration, marketing and educational
materials, and Patient Safety Program Tools. There is
a full archive of the Patient Safety Newsletters. Look
to this site for announcements from the Patient Safe-
ty Program, such as the annual call for submissions to
the Patient Safety Awards.
The Center for Education and Research in Patient
Safety (CERPS), the educational component of the
Patient Safety Program, provides a dynamic resource
on its own website at: https://www.usuhs.mil/cerps/-
index.shtml. The CERPS focus is on educational
resources specifically targeted to professional stake-
holders, and on training information and opportuni-
ties. There is an interactive component which is
linked to didactic training modules. Providers are
directed to a number of patient safety resources, and
will find the most current alerts and practice recom-
mendations on this site.
Together, these related websites provide an integrated
approach to communicating the scope, efforts and
message of the DoD Patient Safety Program. All DoD
patient safety providers are encouraged to make fre-
quent access to both websites a routine part of their
practice protocol.