INSIDE: DoD Patient Safety Website Redesigned Page 2
Patient
Safety
A quarterly newsletter to assist DoD hospitals with improving patient safety
DoD PATIENT SAFETY
PROGRAM RESTRUCTURED
New Organization Underscores Leadership Commitment
T he Patient Safety Program has under-
gone a review and restructuring. A
new organization chart has been devel-
oped; a Division Director has been named,
and official charters have been written
outlining the roles and responsibilities of
each operational unit within the Program.
The Patient Safety Division shall reside at
TRICARE Management Activity (TMA) with-
in the Patient Safety Division of the TMA
Office of the Chief Medical Officer
(OCMO). Policy and executive oversight
will be provided by the Patient Safety
Executive Council and the Tricare Clinical
Quality Forum. Senior leadership is rep-
New organization structure for the DoD Patient Safety Program.
WINTER 2003
F0011
Page 2 AHRQ Website
Page 2 Newsletter Links
Page 4 Calendar
Page 4 Patient Safety Awareness Week
MEET CAPT
DEBORAH MCKAY
Division Director
Patient Safety Program
resented on both of these forums. CAPT
Deborah McKay, NC, USN has been
appointed Division Director of the Patient
Safety Program.
I n September, CAPT Deborah McKay,
NC, USN was assigned to serve as
Director of the DoD Patient Safety
Program. Although new to patient
The Patient Safety Planning and
Coordination Committee (PSPCC) – a safety, CAPT McKay brings a wealth of
newly named, streamlined version of the management and leadership experi-
Patient Safety Working Group – is respon- ence to the Program. She has created
sible for coordinating patient safety activi- and led military and national award-
ties, analyzing patient safety data, and pro- winning programs in the areas of
viding patient safety training across the health promotion and population
services. CAPT McKay will chair the health. A community health nurse,
Committee. Continuity will be assured by CAPT McKay is well versed in the con-
the continued representation on this cepts of prevention and views this new
Committee of each Service, as well as assignment as a different, but related,
Continued on page 4 opportunity to ensure the health and
safety of military beneficiaries.
CAPT McKay sees coordinating and
strengthening support for the Patient
Safety Programs across each Service
area as the primary challenge for the
coming year. Her vision includes
offering more frequent, specialized
training opportunities, and improving
the data flow between the MTFs and
the central Registry at AFIP. Creation
of a seamless stream of data will drive
evidenced-based patient safety deci-
sions, a primary goal in the effort to
establish the Military Health System as
a benchmark for patient safety.
PATIENT SAFETY ON-LINE
DoD Patient Safety Website
Plans February Launch
T he DoD Patient Safety Program is
pleased to announce the up-com-
ing February 2003 launch of its newly
designed website. This exciting new
resource promises a comprehensive,
one-stop shopping site for patient safety
information related to the DoD
Program and patient safety in general.
Designed by Park City Solutions, with
input from the Patient Safety Planning
and Coordination Committee (PSPCC)
and TMA, this new website will com-
pletely replace the existing website.
Built with the user in mind, it has visual
appeal and a clear, easy to navigate,
interactive format. Across the top of
the home page, you will find News,
Frequently Asked Questions, Links,
Calendar of Events, and the Patient
Safety Library. The left side of the page
features access to information about the
Patient Safety Program, Patient Safety
Center, PSPCC and DoD Patient Safety
Conferences and Training.
Anyone working in patient safety knows
that the amount of information about
patient safety, both in print and on the
web, is overwhelming. At an early
training session, an attendee asked if
the Patient Safety Program could pro-
vide some direction in discerning which
resources are actually helpful. This
website will provide that opportunity.
Administered by TMA, content will be
submitted by representatives from each
of the Services, the Patient Safety Center
at AFIP and the Center for Education
and Research at USUHS. Important
Military Health System (MHS) patient
safety information will be highlighted.
Links to each of the Service websites
will allow users to keep abreast of their
individual program activities. The News
section and the Calendar of Events will
provide updates on happenings outside
the MHS. Hyperlinks will allow easy
access to referenced organizations,
conferences and educational opportuni-
ties. The Patient Safety Library will pro-
vide a compilation of recommended
patient safety materials, covering those
in circulation, as well as emerging pub-
lications. Users will find it a compre-
hensive guide, and can be confident
that Library resources have been
reviewed for historical, academic or
practical value.
The exact date of the Website launch is
not yet certain. You can continue to
check the existing website –
www.afip.org/PSC – can be checked for
information on access to the new site.
New On-line AHRQ
Resource
T
he Agency for Healthcare
Research and Quality will soon
offer a new website designed to educate
healthcare providers about medical
errors in an engaging, anonymous and
blame-free environment. Sponsored in
part by the National Patient Safety
Foundation, WebM&M is an innovative
on-line, case-based journal and forum
for patient safety and healthcare quality.
You can visit the site at
http://webmm.ahrq.gov.
The website will officially launch in
February, 2003. It will present cases of
actual medical errors, accompanied by
expert, evidence-based commentaries.
Each issue will include a “spotlight
case” with an interactive learning mod-
ule, available to download for educa-
tional use, as well as a users’ forum
linked to cases and commentaries and
links to assorted patient safety
resources. Creators believe that the
2
Patient Safety Links
Interesting Resources To Explore
Four major patient safety organizations
offer on-line newsletters. You are encour-
aged to access and review them on a regular
basis. Amidst the plethora of patient safety
information, these newsletters contain time-
ly, helpful information.
Agency for Healthcare Research and Quality
www.ahrq.org
To access electronic newsletter click on
News and Information, then Newsroom,
scroll to Electronic Newsletter.
Special interest: timely news releases;
newsletter archives.
Institute for Healthcare Improvement
www.ihi.org
To access “Continuous Improvement” month-
ly newsletter, click on Resources, scroll to
newsletter link.
Special interest: Improvement Tip section.
National Patient Safety Foundation
www.npsf.org
To access “Focus on Patient Safety”, the
official quarterly publication of NPSF, click
on Programs, scroll to “Focus”.
Special interest: subscribe free of charge at
info@npsf.org.
VA National Center for Patient Safety
www.patientsafety.gov
To access “Topics in Patient Safety” (TIPS),
scroll down home page to NCPS Spotlight,
click on NCPS TIPS.
Special interest: Dec. 2002 Special Edition
on JCAHO Patient Safety Goals 2003.
For a change of pace, we highly recommend
this fascinating, readable new book focusing
on the scientific and human complexities of
modern medicine. While not exclusively
about patient safety, this book captures the
spirit of providing care in our complicated
and profoundly human system.
COMPLICATIONS by Atul Gawande
(Metropolitan Books, Henry Holt and
Complany, LLC, 2002).
educational value of sharing the lessons
learned from medical error incidents
cannot be overestimated.
Cases are being solicited for possible
posting to the site. All case reports are
anonymous. Writers will receive an
honorarium. If you are interested in
submitting a case, and need assistance,
you may contact Patrice Spath of
Brown-Spath & Associates at:
Patrice@brownspath.com
Patient Safety
In Action
Experiences and sugges-
tions from the field
O ne of the most difficult challenges
facing patient safety managers at
any facility is how to get the attention of
busy doctors, nurses, pharmacists and
other care providers. After reviewing
incident reports, analyzing errors and
articulating lessons learned, the next
step is effectively communicating
changes that will make the system safer.
This may be the hardest step of all.
How, in the midst of overwhelmingly
busy schedules and rotating staff, does
the message of safety heard get heard?
Wuerzburg MEDDAC has created a
super solution to the problem. Meet
SENTINEL SAM – a super hero dedicat-
ed to the cause of health, safety and
improved patient care!
communicating policy and procedure,
she wanted the staff to really hear the
patient safety improvement ideas that
came from the analysis of incidents
reported to her office.
Enter Sentinel Sam! Getting the staff’s
attention is no longer a problem.
Sentinel Sam made his debut on August
2, 2002 at the hospital’s Organization
Day. He was introduced in full cos-
tume, and providers were made aware
that they would soon receive visits from
Sentinel Sam, who would be the bearer
of important safety information.
Since his debut, Sentinel Sam has been
enthusiastically adopted by the staff of
Wuerzburg. He visits wards and clinics
with specific suggestions for safety
improvements. The hospital plans to
expand his profile, and hopes to feature
Sentinel Sam and his safety tips on its
daily newsletter, as well as on short
video clips.
For more information, contact: Marti Blose
at Marti.Blose@wur.amedd.army.mil.
each safety board. Staff could decide
what boards they would visit and when,
as long as at the end of the day they had
visited each board and heard each fif-
teen minute presentation.
This flexible round-robin approach was
well-received by the staff. They appre-
ciated the short, focused training seg-
ments, held often enough throughout
the day that they fit within even the
busiest schedule. The round-robin was
repeated over three days, so that all
staff had ample opportunity to partici-
pate. A separate session for physicians
was provided at their medical staff
meeting. Everyone was rewarded with
patient safety lapel pins or name tag
holders (complements of MEDCOM)
and a Certificate of Attendance with
stickers reflecting completion of each
storyboard presentation.
For more information, contact: Hope
Cox at Hope.Cox@na.amedd.mil.

Ireland Army Community Hospital,

Sentinel Sam (SGT Rueben Salinas) shares
lessons learned with staff members Dr.
Ebena, Mrs. Fraser, Mrs. Singerhouse, LT
Droge, SPC Jasktis; (back) CPT Horn, SPC
O’Grady at Wuerzburg MEDDAC.
CPT Marti Blose, Patient Safety Manager
at Wuerzburg MEDDAC, has found a
creative way to focus on lessons
learned. Recognizing that care
providers are inundated with e-mails,
in-services and other traditional ways of
Fort Knox, Kentucky developed a
“round robin” to introduce their patient
safety program. Under the direction of
Clinical Pharmacist, Dr. Hope Cox the
five-member Patient Safety Committee
created four patient safety story-boards
which focused on the history of patient
safety, reporting adverse events, patient Patient Safety Storyboard from round-robin
safety techniques using needles and IV briefing at IAHC, Fort Knox, Ky.
tubing, and a new process for reporting
near misses.
Does your facility have a cre-
To accommodate their busy staff, the
ative approach to spreading
Committee presented the patient safety the message of patient safety?
story in round robin fashion. Each
story-board, with accompanying fifteen
You are invited to send a short
minute briefing, was set up in a differ- description of your patient
safety initiative to the Editor
ent room. At various intervals from
so that it can be shared in the
6:30 am to 6:30 pm, they announced an
hour long patient safety round-robin next Newsletter. Send copy to
briefing. Over the course of the day Editor: poetgen@aol.com.
each staff member was expected to visit

3

CONFERENCE
CALENDAR
DOD PATIENT SAFETY TRAINING
Jan. 22 - Jan. 24, 2003 - Arlington, Virginia
April 29 - May 1, 2003 - West Coast
July 30 - Aug. 1, 2003 - Europe
www.afip.org/PSC
INSTITUTE FOR HEALTHCARE
IMPROVEMENT
2nd Annual Forum for Improving
Children’s Health
March 5 - March 7, 2003
Orlando, Florida
www.ihi.org
NATIONAL PATIENT SAFETY
FOUNDATION
5th Annual NPSF Patient Safety Congress
March 12 - March 15, 2003
Washington, D.C.
Integrity and Accountability in Clinical
Research
May 6 - May 8, 2003
Washington, D.C.
www.npsf.org
Continued from page 1
Health Affairs, TMA, the Armed Forces
Institute of Pathology (AFIP) and the
Uniformed Services University Health School
(USUHS). The PSPCC will coordinate
patient safety activities across the services
and within the AFIP, USUHS and TMA.
For patient safety personnel in the field, the
practical effect of this organizational
restructuring is a more efficient and more
effective Patient Safety Program. Better
coordination of efforts will result in
improved services to MTFs. At a recent
Patient Safety Program retreat, with repre-
sentatives of the PSPCC, CAPT McKay
explained that the restructuring is the first
step in an on-going effort to support the
needs of the Air Force, the Army and the
Navy as they do the important work of
improving patient safety across the Military
Health System.
PATIENT SAFETY ships with their patient communities
and help patients become involved in
AWARENESS their own heath care. The National
WEEK Patient Safety Foundation is offering a
list of activities, as well as toolboxes
Plan an Activity for your for hospitals that are members of their
Stand Up Patient Safety campaign. You
Facility can visit the NPSF website at
www.npsf.org for more information or
M arch 9 – March 15, 2003 has
been designated the second
annual Patient Safety Awareness Week.
activity suggestions.
The DoD Patient Safety Program sup-
Initially launched in 2002 by PULSE of
ports Patient Safety Awareness Week,
New York, a patient support and advo-
and encourages all MTFs to plan at
cacy group, Patient Safety Awareness
least one activity highlighting patient
Week is a national education and
safety. Please share your plans for
awareness-building campaign for
Awareness Week by sending them to
improving patient safety at the local
the Newsletter. They will be pub-
levels. It is endorsed by the National
lished and will provide a DoD patient
Patient Safety Foundation (NPSF).
safety awareness resource - a con-
crete way all of us together can pro-
Hospitals and staff are encouraged to
mote patient safety within the MHS.
focus on activities which build partner-
Patient
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
on 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
Please forward comments and suggestions to the editor at:
DoD Patient Safety Center
Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
Phone: 301-295-8115 • Fax: 301-295-7217
E-Mail: patientsafety@afip.osd.mil • Website:www.afip.org/PSC
E-Mail to editor: poetgen@aol.com
DIVISION DIRECTOR, PATIENT SAFETY PROGRAM: CAPT Deborah McKay
ACTING DIRECTOR, PATIENT SAFETY CENTER: Gaetano F. Molinari, MD, MPH
SERVICE REPRESENTATIVES:
ARMY: Col. Judith Powers, AN
NAVY: Ms. Carmen Birk
AIR FORCE: Lt. Col. Beth Koshin
Lt. Col. Cynthia Landrum-Tsu
PATIENT SAFETY BULLETIN EDITOR: Phyllis M. Oetgen, JD, MSW