INSIDE: Portsmouth Shares FMEA Experience Page 3
Patient
Safety
A quarterly newsletter to assist DoD hospitals with improving patient safety
MedTeams Begins Labor &
Delivery Study
Teamwork Hypothesis to be Tested
he DoD Patient Safety Center is working
T closely with MedTeams, a healthcare team
coordination initiative, in a new study designed
to assess the impact of better clinician team-
work on the quality of obstetrical care provided
to patients. The goal of this MedTeams
research project is to determine whether Labor
and Delivery units structured into teams with
MedTeams skills training will demonstrate con-
sequentially better clinical unit performance
than units without teams and teamwork train-
ing. The study will utilize a standardized set of
measures and a randomized, cluster-based
design approved by a specially appointed scien-
tific oversight group. The study promises
results which will have a high degree of reliabil-
ity.
Interest in this project is widespread. It is
receiving support from both the American
College of Obstetrics and Gynecology and the
Harvard Risk Management Foundation. They
believe that a positive outcome will be extreme-
ly helpful, both in providing a scientific basis
for the value of teamwork, and in reducing the
current malpractice burden to the obstetrics
profession. In addition to nine participating
civilian hospitals, eight DoD facilities are
involved: Madigan and Tripler Army Medical
Centers, Naval Medical Centers at San Diego,
Portsmouth and Bethesda, and Bremerton and
Camp Pendleton Naval Hospitals. The study is
especially important because the results,
whether positive or negative, will be relevant
not only to the safety and welfare of military
medical beneficiaries, but also to the practice of
obstetrics on a national level.
The medical teamwork concept has yet to
be fully tested in a well designed, prospective,
scientifically controlled study such as this Labor
and Delivery validation project. After pilot test-
SUMMER 2002
ing at Beth Israel Deaconess Medical Center
and Madigan Army Medical Center, the formal
study will begin in October, and run through
March 2004. Participating sites will be ran-
domly assigned to either the control group or
the experimental group. Experimental sites will
install the MedTeams system, and both groups
will make repeated collections of study meas-
ures. The measures will be analyzed to deter-
mine if consequential improvement in care
processes, outcomes or satisfaction has
occurred as a result of better teamwork.
The MedTeams teamwork system is based
on the principles of aviation crew teamwork. It
is particularly relevant to those medical envi-
ronments where effective real-time, face-to-face
communication and coordination are essential
to safe and effective patient care. The work
processes of both emergency departments and
labor and delivery fit this model. Retrospective
reviews of closed claim files in these environ-
ments suggest that 40% or more of the mal-
practice events that occur could be prevented
or mitigated by better clinician teamwork.
A MedTeams course has already been
developed for emergency departments, and a
number of MTFs have participated in this train-
ing and implementation. As of May, the follow-
ing military hospitals have completed
MedTeams ED instructor training: Naval
Hospitals at Jacksonville, Bethesda, Camp
Pendelton, Bremerton, Great Lakes and
Okinawa, Evans and Dewitt Army Community
Hospitals, Womack Army Medical Center.
For more information on MedTeams, con-
tact Alan Cash, RN, JD at the Patient Safety
Center, casha@afip.osd.org. Updates on the
progress and results of the study will be provid-
ed.
F0011
Page 2 Share Your Story
Page 2 Safety Links
Page 4 Calendar
Page 4 Symposium for CEOs
Helpful Suggestions
…from DoD Patient Safety Training
Patient Safety Tools from Naval Hospital,
Naples
While attending the August Patient Safety Training
session, CDR Kathryn A. Summers, Department
Head, Quality Management, Naval Hospital Naples,
Italy offered to share several tools her facility
used to comply with the JCAHO Patient Safety
Standards during their April 2002 review. Her
material can now be accessed on the Patient
Safety Center website at: www.afip.org/PSC. Click
"On-line conference information and registration"
located in the left hand column under
"Conference Materials". Enclosures include time-
lines, presentations, surveys and handouts. These
tools will be helpful in implementing your patient
safety programs, as well as in preparing for
JCAHO review. You may contact CDR Summers
with any questions at:
ksummers@naples.med.navy.mil. The Patient
Safety Working Group wishes to thank CDR
Summers for her enthusiasm and assistance.
Pay Close Attention to RCAs
During the RCA presentation at the August train-
ing session, attendees were reminded that all
RCA's should be verified for completeness using
the JCAHO "minimum scope" document. For a
copy of this document, access the JCAHO website
at www.jcaho.org. Click on "Standards FAQ", then
"Comprehensive Accreditation Manual for
Hospitals", then "Sentinel Event Policy and
Procedures". Attendees were reminded to form
RCA teams with care. Including all levels of per-
sonnel closest to an event enhances the scope and
depth of analysis. Command endorsement of the
RCA recommendations was stressed. To ensure
that leadership is part of the process, schedule an
out-briefing with the hospital commander at the
time the team is formed.
Patient Safety
Program
Expands
Operations
Patient Safety Center at AFIP
Welcomes New Staff
T his is an exciting time for the MHS Patient
Safety Program. In April 2002 the
Program received its first significant allocation
of funds. With this support, the vision of a cul-
ture of safety across the full spectrum of mili-
tary health care moves closer to a reality. Every
level of patient safety effort is being strength-
ened, from additional patient safety personnel
in MTFs, to an enhanced administrative system
for the DoD Patient Safety Center at AFIP.
Staffing the Patient Safety Center has been an
initial focus of attention. The Center plans to
have a full compliment of staff on board shortly.
Positions include two nurse risk managers, an
IT professional, a human factors engineer, and
administrative support.
With adequate staff in place the Patient Safety
Center will be able to more aggressively pursue
its mission of enhancing healthcare safety for all
MHS beneficiaries. As an integral part of that
mission, the Center is charged with establishing
and refining a central, standardized error and
safety healthcare database - the MHSPSC
Registry. All MTFs have now received training
Call for Articles
Do You Have A Story To Share?
T he National Patient Safety Foundation is
soliciting articles on patient safety for its
quarterly newsletter Focus on Patient Safety.
The Newsletter is aimed at practitioners
involved in exploring the professional, con-
sumer and systems issues related to patient
safety, and provides an opportunity for those
working in the field to share information and
experiences.
The Newsletter is soliciting articles for two fea-
tures: "As I See It" and "Solutions". Stories
submitted to "As I See It" should be personal-
ized accounts of the writer's experiences,
insights or lessons learned in patient safety.
Articles appropriate for "Solutions" are case
and are sending reports to the Center. In order
to more effectively process and analyze reports,
the Center is upgrading its data entry capacity.
Over the coming year it will complete contracts
for strategic components of the Registry such as
MedMARx and Taproot, and will test an interim
database developed by the Army. Planning and
design of a highly sophisticated database which
will enhance both reporting and analysis of
patient safety information is well underway, with
a tentative operational date of FY 04.
Providing information derived from the MHS
error and safety experience is also an important
Center responsibility. Quarterly reports based
on the summary and RCA information provided
by the MTFs will continue to be generated.
With added staff support and improved data
processing capacity at the Center, an immediate
goal is to improve the analysis of the data
received so that trends, lessons and recommen-
dations for improved practice can be discerned
and shared.
Another exciting initiative which will immediate-
ly benefit everyone involved in safety efforts is
the total redesign and upgrade of the patient
safety website. This is a cooperative effort of
the Patient Safety Center and the Patient Safety
Working Group. Designed to be user-friendly,
interactive and instructive, the goal is to provide
an on-line resource that includes information
on the MHS Patient Safety Program as well as a
fully developed and continually updated library
of the most topical patient safety references.
Plans call for the website to be accessible
sometime in November.
histories in patient safety that describe solutions
to particular patient safety problems.
Many attendees at the DoD patient safety train-
ing sessions this past year have shared their
experiences in implementing patient safety pro-
grams within individual MTFs. DoD personnel
have creatively and enthusiastically enhanced
patient safety within the military healthcare sys-
tem. If you have a story to tell or a safety initia-
tive that you think others would like to try, we
encourage you to take advantage of this unique
opportunity to share your DoD experience with
a large and diverse audience.
For details on article requirements and submis-
sion deadlines, see Focus on Patient Safety: Call
for submissions at www.npsf.org. Call
Managing Editor Lori Zipperer at 847-328-5075
with specific questions.
2
Patient Safety Links
Interesting Resources To Explore
Joint Commission on Accreditation of
Healthcare Organizations
www.jcaho.org
JCAHO has announced six National Patient
Safety Goals for 2003. They are: to improve
the accuracy of patient identification, com-
munication among caregivers, safe use of
high-alert meds, safe use of infusion pumps,
effectiveness of alarm systems; and to elim-
inate wrong-site surgery. The goals are
accompanied by clear, evidence-based rec-
ommendations to help reduce these health
care errors.
Agency for Healthcare Research and Quality
www.ahrq.gov
Five Steps to Safer Health Care. A helpful
fact sheet for patients developed by Federal
agencies in the Quality Interagency
Coordination (QuIC) Task Force, in partner-
ship with other health care purchasers and
providers.
Inpatient Quality Indicators (IQI) software.
Free software available to hospitals to help
perform a quality check on inpatient care
provided.
National Quality Forum
www.qualityforum.org
Mission: not-for-profit membership organiza-
tion created to develop and implement a
national strategy for health care quality
measurement and reporting.
Reports: A National Framework for
Healthcare Quality Measurement and
Reporting. Identifies seventeen NQF-
endorsed principles and policy statements
for improving healthcare through measure-
ment and reporting.
Improving Healthcare Quality for Minority
Patients. Specific steps promise to signifi-
cantly improve healthcare quality provided
to racial and ethnic minority populations.
Serious Reportable Events in Healthcare.
Identifies twenty-seven serious adverse
events that are largely preventable and are
of concern to the public and healthcare
providers.
Nonmembers can access Executive
Summaries and order information.
National Academy for State Health Policy
www.nashp.org
Mission: excellence in state health policy
and practice.
Special Interest: Statewide Patient Safety
Coalitions: A Status Report, published May
2002. Also, see the Quality and Patient
Safety section for up-to-date state respons-
es to patient safety issues.
Legal Medicine
www.afip.org/Departments/legalmed/lmof.h
tml
Journal containing an analysis of current
medicolegal and risk management issues
published annually by the Department of
Legal Medicine at the Armed Forces
Institute of Pathology. 2002 journal con-
tains three articles related to patient safety:
"Beyond Rhetoric: Teamwork, A Real
Response to Patient Safety"; "Standardizing
Medication Error Reporting Using
MedMARx"; "Obstacles to Error Reporting in
a Patient Safety Program".
Patient Safety
In Action
Experiences and sugges-
tions from the field
B eginning July 2001, JCAHO standard
LD.5.2 became mandatory for all in-
patient facilities. The standard requires leaders
to "ensure that an ongoing proactive program
for identifying risks to patient safety and reduc-
ing medical/healthcare errors is defined and
implemented". As part of this program, high-
risk processes must be identified and priori-
tized. One high-risk process must be selected
annually for review. Potential failure modes and
effects must be identified, and the process must
be redesigned to minimize the risk or protect
patients from its effects. The redesigned
process must be tested, measured for effective-
ness, and maintained over time. By June 30,
2002 all hospitals should have completed their
first annual Failure Mode Effect Analysis.
The DoD Patient Training sessions include
a presentation on failure mode and effect analy-
sis, with special attention given to the
Healthcare Failure Modes and Effects Analysis
(HFMEA) system developed by the VA National
Center for Patient Safety. Despite this introduc-
tion, many busy healthcare providers in the
field find the requirement to conduct this
prospective assessment daunting. We are
pleased to share the following FMEA experience
from Portsmouth Naval Medical Center. They
felt their efforts were rewarded by a positive
impact on patient care. We thank Portsmouth
for sharing their candid assessment of the
process, and we hope other facilities find
encouragement in their good work.
Running a Failure Mode and Effects
Analysis Team
Our Experiences at NMC Portsmouth
Just the mention of the term Failure Mode
and Effects Analysis (FMEA) can sometimes
cause people to run and hide. The time and
dedication required to make it a successful ven-
ture can appear to be overwhelming until the
process is understood. When done properly,
however, it can be a very rewarding experience.
Staff members working within the
Oncology Product Line at Naval Medical Center
Portsmouth voiced concerns about the high-risk
process of ordering, dispensing and administer-
ing chemotherapeutic agents. It was felt that an
effective, sustained systems change was needed
to improve patient safety.
A core group of staff, which included the
Oncology Product Line Leader, the Risk
Management Product Line Leader and a Process
Improvement Coordinator, met to determine the
best way to address these concerns. They
decided that a FMEA would be the best
approach, since the FMEA process is a system-
atic method of identifying and preventing prod-
uct and process problems before they occur.
An interdisciplinary team of stakeholders
was convened. It included physicians, nurses,
pharmacists and risk managers, with ad hoc
representation from laboratory staff. Within this
group the inpatient, outpatient, adult and pedi-
atric populations were all represented.
Articles regarding the impact of
chemotherapeutic medication errors as well as
reading that described the FMEA process were
distributed as a pre-meeting assignment. When
the twelve member group initially met, the ten
steps of the FMEA process were reviewed and
ground rules were established. (The impor-
tance of establishing ground rules cannot be
emphasized strongly enough when approaching
a change in deeply imbedded practices.) It was
agreed that the team would meet weekly for one
hour at a set time and place.
Over the following four months the group
followed the FMEA steps. First, a flow chart was
developed to understand the current process.
This ultimately was diagrammed as a 21-step
process, each with multiple sub-steps. Then,
the possible failures and effects of the failures
of each step were reviewed, along with the root
causes that could contribute to actual or poten-
tial failures.
A review of the process clearly indicated
that changes to all twenty-one steps could not
be made at one time due to the enormity of the
project. It was also apparent that the inpatient,
outpatient, adult and pediatric areas could not
all be addressed simultaneously. It was agreed
that the initial efforts of the team would focus
on the adult outpatient population. There was
discussion and understanding that all improve-
3
ments could be utilized in the other areas as
appropriate without waiting for a formal team
to convene to specifically address these other
patient settings.
A three point criticality scale to determine
the likelihood, severity and probability of failure
was employed. Each member of the group was
instructed to choose the top three steps in the
process he or she felt had the highest impor-
tance, and rank the steps on the criticality scale.
Interestingly, most members of the team chose
the same three steps: ordering
(incomplete/unclear chemotherapy templates);
administration (two RNs checking/verifying
orders, uniformity in calculation of body sur-
face area, checking/reporting abnormal lab
results, availability of previous orders); and
patient discharge (complete discharge instruc-
tions, notification regarding further treatment).
Reduction strategies were discussed and
agreed upon. They included development of
new chemotherapy templates, new unit policies,
staff education, chart audits, revised patient
education and improved methods of communi-
cation. A timeline that outlined the actions nec-
essary to implement the recommended changes
was developed. Prior to making any changes,
staff satisfaction surveys and patient flow (time)
studies were obtained to establish a baseline for
measuring the effectiveness of the changes.
One challenge encountered in the FMEA
process was managing the tensions inherent in
the interdisciplinary team. Also, as with any
long-term project, sustaining the focus and
energy of the group proved extremely difficult.
The FMEA team continues its efforts to imple-
ment the action plans, meeting on a monthly
basis to monitor progress. The group looks
forward to reporting the results after their six
month review. All team members found the
FMEA process to be a rewarding experience,
and they believe it has had a positive impact on
the care provided to our beneficiaries. They
are all to be commended for their dedication to
this long-term project.
If you are interested in forming a FMEA team
and would like additional details on our experi-
ence, please contact CDR C. Andreno, (757-
953-7579, DSN 377-7574) or C. Chinery, RN,
(757-953-7278, DSN 377-7278).
 DoD Patient grate these considerations into a document that
definitively presents the business case for
CONFERENCE Safety Center patient safety. Featured speakers at the
Symposium will include Carolyn M. Clancy, MD,
CALENDAR Co-Sponsors Acting Director of ARHQ, Dennis S. O'Leary, MD,
President of JCAHO, and Gail R. Wilensky, PhD,
Symposium John M. Olin Senior Fellow, Project HOPE.
NATIONAL QUALITY FORUM Center joins with AHRQ
To date, education and training efforts of
October 1-2, 2002 and JCAHO
the DoD Patient Safety Center have been focused
Washington, D.C. on the military health system providers at the
www.nqf.org
T he DoD Patient Safety Center is collaborat-
ing with the Agency for Healthcare
Research and Quality (AHRQ) and the Joint
medical treatment facility level. By participating
as a co-sponsor of the ARHQ-JCAHO
AMERICAN SOCIETY FOR QUALITY Commission on Accreditation of Healthcare Symposium, the Patient Safety Center intends to
Hospital System Failure Mode and Effects Organizations (JCAHO) to present "Building bring the concepts of the patient safety move-
the Business Case for Patient Safety: A ment to the attention of senior level military
Analysis
Symposium for CEOs.” The Symposium will health system commanders and administrators.
September 30 - October 1, 2002
be held at the Crystal City Marriott in Arlington,
Milwaukee, Wisconsin Participating in the Symposium from the
Virginia on September 26 and 27, 2002.
Department of Defense will be representatives
Healthcare Executive Leadership Summit The Symposium is designed to review data from the office of the Assistant Secretary of
October 23, 2002 and foster discussion among the participants for Defense for Health Affairs, the Surgeons
the purpose of building a business case for General, commanders of major military system
San Jose, California
patient safety initiatives. Its thesis is that the commands, and the DoD Patient Safety Center.
www.asq.org
business case for patient safety is more than a
financial argument. The patient safety move-
INSTITUTE FOR HEALTHCARE ment is based on ethical, political, evidential,
IMPROVEMENT legal, marketing, and human resources founda-
International Summit on Achieving tions. The purpose of the Symposium is to inte-
Workforce Excellence
October 8-9, 2002
Boston, Massachusetts

14th Annual National Forum on Quality

Improvement in Healthcare
Patient
December 8-11, 2002
Orlando, Florida
www.ihi.org Safety
Patient Safety is published by the Department of Defense (DoD) Patient Safety Center,
VHA, INC located at the Armed Forces Institute of Pathology (AFIP). This quarterly bulletin provides periodic updates
Partnership Symposium 2002 - Smart on the progress of the Tri-Service Patient Safety Program at all military medical treatment facilities.
Design for Patient Safety Please forward comments and suggestions to the editor at:
October 14-16, 2002 DoD Patient Safety Center
Washington, D.C. Armed Forces Institute of Pathology
www.vha.com or call 877-713-4238 1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
Phone: 301-295-8115 l Fax: 301-295-7217
E-Mail: patientsafeity@afip.osd.mil l Website: www.afip.org/PSC

ACTING DIRECTOR, DoD PATIENT SAFETY CENTER: Gaetano F. Molinari, MD, MPH
CHAIR, DoD PATIENT SAFETY WORKING GROUP: Capt. Frances Stewart, MC, USN
SERVICE REPRESENTATIVES:
ARMY Col. Judith Powers, AN
NAVY Ms. Carmen Birk
AIR FORCE Lt. Col. Beth Kohsin
Lt. Col. Cynthia Landrum-Tsu
PSC COORDINATOR: Richard L. Granville, MD, JD
PSC REPORTS: Alan Cash, RN, JD
PATIENT SAFETY BULLETIN EDITOR: Phyllis M. Oetgen, JD, MSW