THIS ISSUE: PATIENT SAFETY PROGRAM TODAY
Patient
Safety
A quarterly newsletter to assist DoD hospitals with improving patient safety
PATIENT
SAFETY
PROGRAM
BUILDS ON
SUCCESS
Program Director Outlines
Accomplishments and Goals
T he DoD Patient Safety Program
has been in existence for approxi-
mately three years. For the past two
years, the Program has experienced
some significant gains along with grow-
ing pains. Now I think the growth spurt
is paying off as we enter into our fourth
year with a very ambitious and exciting
agenda. The Patient Safety Executive
Council (PSEC), comprised of the three
Surgeons General, the President of
USUHS, the Director of AFIP, and
chaired by Dr Tornberg, has recently
approved the 2004 Strategic Plan for
Patient Safety.
The Strategic Plan is divided into three
phases: Development Phase,
Implementation Phase and the
Maturation Phase. The Development
Phase largely took place over the past
FALL 2003
year when we created our foundation
by establishing the PSEC, distributing
automated tools to the field in the form
of a medication error reporting system
(MEDmarx) and a root cause analysis
tool (TAPROOT©), requiring mandato-
ry monthly reporting of medical errors
AND near misses to the Patient Safety
Center, and identifying the requirements
of an enterprise-wide patient safety
reporting system.
The Implementation Phase will occur
during FY 04-05. This Phase will
include pilot testing of the enterprise-
wide patient safety reporting system,
establishing electronic Safety Alerts
that will originate at the Patient Safety
Center, and focusing on Health Care
Team Coordination training tailored to
the needs of the MTFs. Two ground
breaking initiatives will also be intro-
duced. The first DoD Patient Safety
Awards will be presented at the TRI-
CARE conference in January 04. The
Awards will be given to those MTFs or
Operational Units that have improved
the medical safety of their organization
through Technology, Policy and/or
Procedure, and Team Training initia-
tives. The other exciting initiative is the
Bar-Code Point of Care Integrated
Product Team which has been formed
F0011
Page 2 Thanks and Farewell
Page 3 New Director for PSC
Page 5 USHUS Education Center
Page 6 Service Reps Share Plans
to outline the requirements of establish-
ing a seamless bar-code system that will
range from outpatient dispensing of
medication to bedside inpatient medica-
tion administration. Bar-code technolo-
gy has been shown to reduce medica-
tion errors by upwards of 60%.
Finally, in the Maturation Phase, we will
see the pay-off of the previous two
Phases. In this Phase the standardiza-
tion of data collection will allow the
Patient Safety Center to analyze and
trend medical errors, near misses, and
hopefully, troubleshooting initiatives,
also known as Failure Modes Effect and
Analysis.
Achieving these lofty goals will not be
easy. It requires change and change is
never easy. In the end though, instead
of 134 facilities reporting 134 different
ways, we all will be on “the same sheet
of music”. We promise to make the
data that you submit meaningful to you
and not just a “one-way push”. Bear
with us in the future; we will listen to
you and learn from you. Thanks to all
of you for what you do every day.
CAPT Debbie McKay
Thanks And Farewell
Early Leaders Reassigned
C
APT Frances Stewart and Col. Judy
Powers, two of the original mem-
bers of the Patient Safety Working Group,
have been reassigned. They, along with
others on the Working Group, were
instrumental in designing and standing up
the DoD Patient Safety Program (PSP).
Each of these leaders contributed greatly
to the successful Program that we
describe in the Newsletter today. We
thank them and wish them well in their
new endeavors
CAPT Stewart, now on temporary duty
assignment, chaired the Patient Safety
Working Group from its inception in
October 2000 until its restructuring in
September 2002, when she became
patient safety liaison with Health Affairs.
Under her leadership the Group devel-
oped a patient safety reporting tool, pilot
trained five facilities in its use, developed
the patient safety curriculum and ran the
training sessions for patient safety per-
sonnel. CAPT Stewart assisted in the writ-
ing of the Department of Defense
Instruction on the PSP. An articulate and
Col. Powers at DoD Patient Safety Training Session
committed spokesperson for patient safe-
ty, CAPT Stewart was an effective catalyst
in making the Patient Safety Program a
reality in the military health system.
Col. Judy Powers, AMEDD Patient Safety
Program Manager from January 2000
until July 2003, served concurrently as
the Army representative to the DoD
Patient Safety Program. While overseeing
implementation of the AMEDD program,
Col. Powers actively participated in the
development of the DoD PSP. She helped
train DoD patient safety personnel as a
platform instructor and RCA team facilita-
tor, contributed to the on-going design of
an information management and technol-
ogy system, and shared resources and
documents from the AMEDD program,
most notably the extensively used Patient
Safety Tool Kit. As consultant for quality
management and patient safety to the
Great Plains Regional Medical Command
at Fort Sam Houston, TX, Col Powers con-
tinues to ensure patient safety within the
military.
2
Patient Safety Links
Interesting Resources To Explore
AHRQ WebM&M
http://webmm.ahrq.gov
On-line case-based journal and forum for
patient safety. Includes expert commen-
tary and video simulations. Cases this
month include delay in treatment, mis-
placed NG tube, wrong-site surgery, lab
error. CME credit is available; submitting
cases is easy and anonymous. We highly
recommend this resource.
National Patient Safety Foundation
www.npsf.org
"Focus on Patient Safety", Vol 6, Issue 3,
2003. Article on Root Cause
Analysis includes personal story of inci-
dent by patient's family and technical
root cause review by NPSF board member
Paul Gluck, MD. An interesting look at a
painful incident from both patient and
provider perspectives.
Journal of the American Medical Association
http://jama.ama-assn.org
"Medical Injuries and Length of Stay,
Charges, Mortality" - JAMA, Oct. 8, 2003,
Vol 290, No. 14, p.1868. Use of Patient
Safety Indicators to identify medical
injuries.
Wall of Silence
www.amazon.com
"The Untold Story of Medical Mistakes
that Kill and Injure Millions of Americans",
Rosemary Gibson and Janardan Prasad
Singh, Lifeline Press (May 2003).
This book uses real-life stories to put a
human face on medical mistakes.
Rosemary Gibson, a leader in innovation
in health care, will speak at the JCAHO
National Conference on Quality and
Safety in December, where her book will
be distributed to attendees.
University of Michigan Health System
Patient Safety Toolkit
www.med.umich.edu/patientsafetytoolkit/
"Improving Patient Safety In Hospitals:
Turning Ideas Into Action"
This toolkit, developed as a resource for
clinicians and administrative leaders,
presents ways to turn patient safety
ideas into practical and achievable
strategies.
NEWS FROM THE reported, and there remains substantial
variability in the way different Services
and fairly technical, and because RCAs are
episodic, personnel rarely develop a com-
PATIENT SAFETY report events. Standardizing reporting fort level performing the RCA process.
tools and processes among the Services is
CENTER one aspect of this goal. Considerable The Charter for the Patient Safety Center
Feedback and Suggestions progress has already been made in this directs it to serve as a change agent for the
direction. Reaching beyond the DoD pro- Patient Safety Program, developing action
Based on Your Reporting gram, Dr. Rake also recognizes emerging plans for addressing patterns of patient
national standards for reporting patient care errors. To date, the PSC has focused
NEW DIRECTOR safety indicators, and he intends to work to mostly on process – reporting. Dr. Rake
JOINS PATIENT increase consistency between these nation- believes that accomplishing these first
al standards and the DoD Registry. Finally, two goals will help the PSC achieve
SAFETY CENTER the PSC will explore the use of other data his third goal, becoming outcome ori-
…Shares Vision and Goals streams already in existence to supplement ented.
the information it already receives.
G eoffrey W. Rake, Jr., M.D., became
the Director of the Patient Safety
Center at the Armed Forces Institute of
Analysis of the correlation between the PSP
data with these external sources will pro-
Over time, Dr. Rake envisions the PSC
developing beyond these initial goals to an
vide a gauge of how completely the PSC is even broader visibility and operational
Pathology in September 2003. Although
capturing data. sophistication. Outreach to physicians and
new to this position, Dr. Rake is no
other direct care providers will move visi-
stranger to military medicine or patient
His second goal is to make the PSC bility beyond patient safety managers.
safety issues. Board certified in Pediatrics
more visible and supportive. He is Working with the Center for Education and
and Allergy and Clinical Immunology, Dr.
actively working with the Services to devel- Research in Patient Safety (CERPS) at the
Rake has just completed a thirty-five year
op better ways for the PSC to assist the Uniformed Services University of Health
career in the Air Force. He comes to the
MTFs. Options under consideration Sciences (USUHS) and building on the con-
Patient Safety Center from TRICARE
include a Help Desk, where MTFs could tinuing education tradition already identi-
Management Activity, where he was Medical
access practical assistance with root cause fied with the Armed Forces Institute of
Director and Director of Clinical Quality
analyses (RCAs) and Site Visits providing Pathology, the PSC is well positioned to
Programs in the Office of the Chief Medical
on-site tailored assistance. Dr. Rake recog- support continuing medical education
Officer.
nizes that completion of RCAs is a daunting opportunities expanding physician involve-
task for field personnel. Sentinel events ment. On the operational level, Dr. Rake
Dr. Rake sees the Patient Safety Center
are infrequent, RCAs are time consuming believes the computerized health care sys-
(PSC) as a dynamic change agent within
Continued on page 4
the DoD Patient Safety Program (PSP).
Information and analysis, action and inter-
action are tools that assist the Services and
PSP design and operate a safer healthcare
system. To make this vision a reality, Dr.
Rake envisions the PSC, with the active
involvement of the Services, becoming
more than a registry and data repository.
Together they must be dynamically involved
with the Military Treatment Facilities
(MTFs) as they administer their programs.
Assuming a more active role in the patient
safety effort presents challenges to the PSC.
Dr. Rake has translated these challenges
into several short and long-term goals.

Improving the reporting efforts within

the DoD patient safety program is the MEET THE STAFF OF THE PATIENT SAFETY CENTER. Front Row: Dr. Rajasri Roy (Epidemiologist),
Bridget Olsen (Human Systems Engineer), LCDR Ron Nosek, (Dep. Director, Pharmacist), Back
first goal for the Patient Safety Center. Row: Mary Ann Davis (Nurse, Risk Manager), Phil Pierce (Information Manager), Dr. Geoffrey Rake
Currently, the reporting system is self- (Director), Nanette Barry(Secretary).

3
NEW DIRECTOR
JOINS PATIENT
SAFETY CENTER
…Shares Vision and Goals
Continued from page 4
tem (CHCSII) being developed within the
DoD presents a critical opportunity to
improve patient safety reporting and trans-
form the MTF’s initial incident reporting
process from a self-reported to an automat-
ed system.
Dr. Rake believes the PSC has only begun to
tap its potential as a partner in the Patient
Safety Program efforts. As the PSC enters
its third full year of operation, these goals
will help reach his vision – a Patient Safety
Center that is a robust, multi-tiered
resource engaged in a collaborative effort
with the DoD Office of the Chief Medical
Officer, Services, and CERPS to minimize
opportunities for error, while to designing
and operating a safer health care system
within the military.
REPORT CARD ON
REPORTING
Suggestions to Improve Monthly Reports
Current Status of Reporting
In November 2002 the first Monthly
Summary Report (MSRs) using a spread-
sheet format was received at the DOD
Patient Safety Center ( PSC). Reporting has
increased over the past year - 93% MTFs
reporting in June 2003; 87% in November
2002. We are are working closely with the
Services to achieve 100% reporting.
Timeliness of reporting, which ensures
complete, accurate review and analysis, has
also improved. The number of MSRs sub-
mitted to the PSC by the 15th of each
month has increased, and the number of
days between an RCA event and submission
of the RCA to the PSC has lessened.
The PSC receives information from all three
Services, reviews each spreadsheet, and
imports the data from the MSRs into an
Access database for review by staff.
Quarterly and yearly reports are created
from this data. The data has also been
requested by the individual services for
service specific reviews.
Monthly Summary Reports (MSRs)
One of the goals of the PSC is to increase
and improve the reporting of patient safety
events. Information included in the MSRs
varies from MTF to MTF. Incomplete,
inconsistent and ambiguous data con-
tributes to flawed or inaccurate conclu-
sions.
To facilitate improved reporting, the PSC
offers these suggestions. Include all
information related to safety issues in
the spreadsheet each month. Describe
an event not identified on the spreadsheet
in the green “other” section of a related
category, or in the “Other/Miscellaneous”
category. The yellow “Comment” areas at
the bottom of the spreadsheet can also be
used for additional information. The yellow
areas are large memo fields, so you can
provide a complete explanation.
Use both the green and yellow narra-
tive sections to describe events. The
narratives reveal detailed information relat-
ed to near misses, actions and areas of
concern or improvement. This information,
even if it does not fit a specified category,
can be inserted into the database.
Descriptive information needs to be cap-
tured in order to build a reliable, rich data-
base with accurate conclusions.
Root Cause Analysis (RCA)
Nearly seventy RCA’s have been submitted to
the PSC since December 2000. Most have
been JCAHO reportable sentinel events.
Formats have included the DOD format, the
JCAHO framework, a combination of the
two, even an ad hoc form. The Patient
Safety Registry staff reviews and analyzes all
reports.
The TAPROOT© product, a systematic way
of analyzing RCA’s that incorporates soft-
ware to sequence and identify conditions
and causal factors, was introduced to the
Services last year to help facilitate the RCA
process. A shortened RCA form, revised to
4
include the TAPROOT© system, was devel-
oped. JCAHO has approved the form,
with the request that their matrix, the
Minimum Scope of Root Cause
Analysis for Specific Types of Sentinel
Events, be utilized with each RCA. We
encourage MTFs to use the revised form
along with the JCAHO matrix so that consis-
tency in analysis and formatting can be
achieved. Access the RCA form on the DoD
Patient Safety Website at
http://patientsafety.ha.osd.mil; the JCAHO
matrix at www.JCAHO.org.
JCAHO reviews RCA outcome measures
closely. Per the JCAHO framework, each
action identified in an RCA should include
an expected implementation date and asso-
ciated measure of effectiveness, or a ration-
al for not taking action. The Outcome
Measures in the DoD RCA form should
include these risk reduction strategies
and measures of effectiveness.
Failure Mode Effects Analysis (FMEA)
MTFs, per the JCAHO requirement for
annual studies consistent with FMEAs,
should be identifying high risk processes in
an effort to reduce or prevent
medical/health care errors. The
TAPROOT© product can be utilized
for FMEAs. The proactive FMEA assess-
ment process, like the reactive RCA
process, uses an interdisciplinary team,
develops a flow chart, focuses on system
issues and develops actions and outcome
measures.
The PSC staff is familiar with both the RCA
and FMEA processes. The PSC will work
closely with the Services, intermediate com-
mands, and MTFs (as appropriate), as a
resource for questions, consultation and
practical assistance.
Does your facility have a creative
approach to spreading the message of
patient safety? You are invited to send
a short description of your patient safe-
ty initiative to the Editor so that it can
be shared in the next Newsletter. Send
copy to Editor: poetgen@aol.com.
CENTER FOR
EDUCATION
AND RESEARCH
IN PATIENT
SAFETY
Education Enhances
DoD Safety Effort
T he DoD Center for Education and
Research In Patient Safety (CERPS) is
the educational component of the Military
Health System (MHS) Patient Safety
Program. The Center was formally char-
tered on 5 March 2003 at the Uniformed
Services University of the Health Sciences
(USU) as a university-wide program,
administratively located within the
Continuing Education for Health
Professional Directorate (CEPH). Our
offices are located in Building 28 on the
National Naval Medical Center Main
Campus.
The mission of CERPS is to address the
patient safety education and research needs
of all Military Health System personnel and
the beneficiaries they care for through
comprehensive educational programs. The
secondary mission of CERPS is to monitor
and coordinate all patient safety education-
al and research activities at the Uniformed
Services University of the Health Sciences.
In collaboration with the three services and
agency programs, CERPS works to identify
and support DoD patient safety initiatives
through the development of innovative
patient safety curriculum, educational
opportunities, and appropriate outcome
evaluations and promotes their implemen-
tation across the DoD MHS.
The scope of CERPS activity includes col-
laborating with representatives of the mili-
tary services to facilitate communication,
coordination and integration of planning,
development and implementation of initia-
tives and programs to assure consistency of
purpose. We work together with federal
and non-federal agencies and institutions to
identify and develop the best patient safety
practices to improve the quality of health
care delivery in the MHS. Through this
monitoring of the broad Patient Safety envi-
ronment, the CERPS works to assess,
review and make recommendations regard-
ing the applicability of non-DoD patient
safety initiatives to the DoD MHS.
The two directors of the CERPS bring
strong and varied backgrounds and experi-
ences to the patient safety effort. CAPT
Glenn Merchant, MC, USN (MD, MPH) flew
Harriers in the Marine Corps prior to
entering medicine and was the first Senior
Medical Officer on board the USS John C.
Stennis CVN74. He is board certified in
both Aerospace and Preventive Medicine
and is the Chair of the American Board of
Preventive Medicine, serves on the ACGME
Residency Review Committee for Preventive
Medicine and has active involvement in
Aerospace Medicine. He brings an extensive
professional experience in aviation safety
and human factors. Eric Marks, M.D.,
Professor of Medicine at USU, is an active
clinician, attending at both the National
Naval Medical Center and Walter Reed
Army Medical Center. He is board certified
in both Internal Medicine and Nephrology,
and also serves as Associate Dean for
Faculty Affairs and Co-Chair of the Section
of Medical Jurisprudence at USU. He has
been involved in medical education for
twenty years including curriculum develop-
ment in medical communication, legal
medicine, and policy development in clini-
cal credentialing and privileges. At present
the staff of the CERPS consists of a Senior
Program Manager with many years of both
educational and administrative experience
and a Program Support Specialist.
The current CERPS activities are varied and
include:

Planning of introductory and
advanced Patient Safety training con-
ferences and TAPROOT© “train the
trainer” programs.

Identifying and distributing the best
practices as they are reported in the
5
medical literature.

Managing a web based list-serve for
DoD Patient Safety Managers

Provision of full USUHS Learning
Resource Center remote library
service access for MTF Patient Safety
Managers.

Monitoring medical/surgical simula-
tion research/activities within DoD.

Provide Health Literacy education
materials for targeted audiences
within DoD.

Development of educational tools
for training in the application of the
Failure Mode Effect Analysis
process.
The staff of the Center is committed to pro-
viding the MHS with the educational pro-
grams and support needed to facilitate the
efforts of dedicated DoD health care pro-
fessionals who work to enhance and main-
tain a “Culture of Patient Safety” for our
patients.
CONFERENCE
CALENDAR
IHI 15TH ANNUAL FORUM ON
QUALITY IMPROVEMENT IN
HEALTH CARE
December 2-5, 2003
New Orleans, La.
www.ihi.org
AMERICAN COLLEGE OF MEDICAL
QUALITY
2004 NATIONAL CONFERENCE
February 19-21, 2004
Orlando, Florida
www.acmq.org
NATIONAL PATIENT SAFETY
FOUNDATION
6TH ANNUAL NPSF PATIENT SAFETY
CONGRESS
May 3-7, 2004
Boston, Massachusetts
www.npsf.org
MESSAGES
FROM SERVICE
REPRESENTA-
TIVES
Service Representatives out-
line goals and plans
ARMY Patient Safety
Program
T he Army Medical Department’s
(AMEDD) Patient Safety Program
involves a variety of clinical and administra-
tive activities to identify, evaluate, and
reduce the potential harm to our benefici-
aries and to improve the overall quality of
health care. The purpose of the AMEDD
Patient Safety Program is to identify and
centrally report actual and potential prob-
lems in medical systems and processes in
order to improve patient safety and health-
care quality throughout the AMEDD.
The U.S. Army Medical Command
(USAMEDCOM), Quality Management
Directorate, Patient Safety Center (PSC)
located at the Medical Command, Fort Sam
Houston, Texas, further facilitates the iden-
tification, management, communication,
coordination, and teamwork in corporate
patient safety systems and process improve-
ment initiatives. The primary objective of
the MEDCOM Patient Safety Center is to fos-
ter a non-punitive, interdisciplinary
approach to decrease unanticipated
adverse health care outcomes.
This promises to be a fast-paced and excit-
ing year at the Patient Safety Center.
Among our goals for the coming year is a
strong focus on patient safety events report-
ing, enhanced training, and improved com-
munication with the medical treatment
facilities (MTF) and regional Patient Safety
Managers.
The foundation of every patient safety pro-
gram resides in its events reporting capa-
bility. The Patient Safety Managers who
worked on the Rapid Action Deployment
teams alongside the contractor can be
proud of their accomplishments in bringing
to life the electronic Advanced Patient
Safety Management Application (e-
APSMA). This application will begin field-
testing and deployment in select Army MTFs
in early 2004. The e-APSMA is a web-
based centralized database designed to
enable the USAMEDCOM Patient Safety
Center, Regional Medical Commands and
MTFs to effectively capture, analyze and
report on all patient program data accord-
ing to MEDCOM, Department of Defense
and Joint Commission Accreditation
Healthcare Organizations requirements. It
is the enterprise solution to facilitating
effective management and analyses of all
MEDCOM Patient Safety Program data.
Training will take center stage this year.
The Patient Safety Center staff is aggressive-
ly creating a Patient Safety Manager Profile
to determine training needs during FY04.
This year’s training focus is TAPROOT©
(basic and advanced), MedMARx (tutorial
and advanced), MEDTEAM (facility and
Train-the-Trainer), Patient Safety (basic and
advanced) and, of coarse, e-APSMA as we
move into field testing and deployment.
Additionally, we will focus select training on
identified Pharmacist “Champions” within
each MTF. This training fully supports
MEDCOM as a “learning organization”.
Finally, our focus in all activities is commu-
nication. The PSC staff is actively reviewing
known newsletters, websites and mail
groups. As we move into FY04, we will
solicit more information from all avenues,
but especially the MTF Patient Safety
Managers. Our goal is to improve the flow
of communication through various medi-
ums to all of our customers. We are com-
mitted to making “the best way the safest
way”.
LTC Steve Grimes
Steven.grimes1@amedd.army.mil
6
NAVY Patient Safety
Program
T he Naval Medicine Risk
Management/Patient Safety Program
has accomplished the following milestones
in relation to policy, program implementa-
tion, and training and information manage-
ment projects during FY03. A policy stan-
dardizing the list of Do Not Use Medical
Abbreviations was developed and distrib-
uted to Navy facilities to assist with meeting
JCAHO Patient Safety Goals. Navy Dental
developed and implemented a Patient Safety
Program based upon the DoDPSP and the
JCAHO Patient Safety Goals at their
Commands. The MEDMARX medication
event reporting system was implemented by
all MTFs for the reporting of medication
related events. Training and feedback have
resulted in an increase in reporting.
Twenty-one MTFs received Patient Safety
contract workers to assist with the imple-
mentation of the Patient Safety program. All
MTF and DTF key personnel received for-
mal Patient Safety training. In addition, the
tri-services were invited to join the fifty-five
Navy risk managers at the Barton Basic and
Applications Modules presented by the
American Society for Healthcare Risk
Management sponsored by BUMED.
BUMED participated in the Institute for
Healthcare Improvement IMPACT
Leadership Conferences supporting our
participating commands. Quarterly VTCs
are held with MTF/DTF risk
management/patient safety staff to discuss
current issues.
For FY04 Naval Medicine will continue to
support the ongoing patient safety efforts
previously established, encourage network-
ing within our communities and focus on
feedback to users. Efforts toward stan-
dardization will continue as will the
engagement of our Specialty Leaders and
Advisory Boards in key patient safety activi-
ties.
Carmen Birk
ccbirk@us.med.navy.mil
Continued on page 8
PATIENT
SAFETY IN
ACTION
Experiences and suggestions
from the field
NAVY ADOPTS
DANGEROUS
ABBREVIATIONS
POLICY
List Reduces Variation, Meets JCAHO
Requirements
N avy Medicine has standardized its list
of Do Not Use (Dangerous)
Abbreviations to meet JCAHO Patient Safety
Goal 2b. The list, which went into effect in
June, is the result of a year long process
among Navy stake-holders. It identifies the
four most common abbreviations which
should no longer be used: Trailing Zeros,
Naked Decimals, U or u for Unit, and the
use of Greek letters for microgram (mcg).
The policy also includes two abbreviations
used in more limited settings whose avoid-
ance is highly recommended: MgSo4 for
magnesium sulfate and MSo4 for morphine
sulfate, and I.U. or IU for International
Unit.
Impetus for standardizing the list began to
grow after publication of the JCAHO
Two slides from the Navy power point presentation. To access tools, go to http://patientsafety.ha.osd.mil
National Patient Safety Goals in July 2002.
Goal 2.b reads: “Standardize the abbrevia-
tions, acronyms, and symbols used
throughout the organization and include a
list of abbreviations and symbols not to
use”. Navy Commands preparing for
January 03 implementation requested guid-
ance from leadership as they struggled with
the complexity of meeting this goal. Led by
CAPT Betsy Nolan, Pharmacy Specialist
Leader and Advisor to the Surgeon General,
a cross specialty group developed a list of
abbreviations, which was distributed to a
variety of process owners across Navy med-
icine for input.
The four abbreviations receiving the great-
est degree of consensus as most dangerous
were designated Do Not Use; two abbrevia-
tions with 90% consensus relating mostly to
OB practice received the Highly
Recommended to Avoid designation. In
addition to meeting this high level of agree-
ment among process owners, the abbrevia-
tions included in the policy are evidence
based. For each Do Not Use abbreviation
there are demonstrated cases of serious
patient harm and death associated with its
use. To maximize the potential for success-
ful implementation, the Navy has limited its
policy to these six abbreviations, although
additional abbreviations can be voluntarily
adopted by individual facilities.
Navy is working closely with JCAHO to
ensure that the abbreviations policy con-
forms to JCAHO requirements. Early confu-
7
sion as to whether the Do Not Use abbrevi-
ations apply to all phases of the medical
system has been resolved. The Navy policy,
like current JCAHO policy, applies only to
handwritten material at this time. Since
JCAHO is now scoring Patient Safety Goals 1
thru 4, compliance with Goal 2.b is even
more significant to the accreditation
process. A JCAHO survey has shown that
Goal 2.b had the highest level of noncom-
pliance among all of the National Patient
Safety Goals. JCAHO will soon be publish-
ing its own list of commonly misunderstood
abbreviations in order to provide additional
guidance and increase compliance. The
Navy policy conforms closely to these
JCAHO standards, and is a timely response
to the needs of facilities facing accredita-
tion.
The Navy has developed a power point
presentation and a poster for use within its
Command. It has shared its Dangerous
Abbreviations policy with the DoD Patient
Safety leadership, and will make its educa-
tional tools available on the Patient Safety
website. Facilities are encouraged to access
these tools for guidance as they develop
their own policies.
Information provided by Carmen Birk,
BUMED Risk Manager
(ccbirk@us.med.navy.mil) and LDCR Ron
Nosek, Deputy Director, Patient Safety
Center (nosekr@afip.osd.mil).
MESSAGES FROM
SERVICE
REPRESENTATIVES
Service Representatives outline goals
and plans
Continued from page 6
AIR FORCE Patient Safety
Program
I n trying to create a safer healthcare sys-
tem across the Air Force Medical Service,
the Major Commands (MAJCOMs) and
medical treatment facilities (MTFs) have
worked diligently over the last two years to
lay the foundation for change. The Air
Force Medical Service is moving from reac-
tive risk management to proactive risk
identification and reduction. By helping
people identify the risk inherent in daily
activities, the Air Force is applying opera-
tional risk management principles to day-
to-day healthcare. Once a risk is identified,
it is accepted and the process continues or,
if the risk is too great to patient and/or
staff, other options with less risk are pur-
sued.
tion and teamwork and is applicable to
everyone in the MTF. Since February 2002,
over 200 personnel have been trained as
instructors and facilitators. First deployed
to high-risk areas (emergency departments,
intensive care units, surgical suites, and
labor and delivery units), eventually all
areas within the MTF will adopt it.
Partnering with the civilian sector is vital.
Three Air Force officers graduated in June
2003 from the Virginia Commonwealth
University (VCU) On-line Executive
Fellowship in Patient Safety and two more
officers are currently enrolled. In addition,
the civilian sector is taking notice of initia-
tives in the Air Force. Maj Joseph Weaver, a
recent graduate of the VCU fellowship, and
his team at Patrick Air Force Base were
selected to receive the American Society of
Health-System Pharmacists Best Practice
Award in Health System Pharmacy for the
project Impact of Pharmacy-Led
Dyslipidemia Interventions on
Medication Safety and Therapeutic
Failure Patients.
Patient Safety is taking hold throughout the
Air Force Medical Service. Through contin-
ued diligence and collaboration at all lev-
els, and in coordination with the other
agencies in DoD, the Air Force will realize
a truly safe healthcare system.
Lt Col Beth Kohsin
Beth.kohsin@pentagon.af.mil
DoD PATIENT SAFETY WEBSITE
The DoD Patient Safety Website is now
accessible at this address:
http://patientsafety.ha.osd.mil
Plan to make regular use of this new DoD
patient safety resource. You can obtain
registration information on DoD training,
access past copies of the Newsletter, link
to patient safety resources, and contact
the Patient Safety Program. Content will
continue to be added and updated.

A crucial step in helping people move to a

Patient
proactive focus is educating them on the
principles and practices of patient safety.
Since the inception of the Department of
Defense Patient Safety Course, over 400 Air
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
Force personnel were successfully trained. on the progress of the DoD Patient Safety Program.
In addition, the Air Force held a seminar in
April 2003 on MEDMARX and TAPROOT©. DoD Patient Safety Program
Office of the Assistant Secretary of Defense (Health Affairs)
These tools, now implemented across the TRICARE Management Activity
Air Force, assist in the collection and analy- Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, Virginia 22041
703-681-0064
sis of patient safety data looking at human
factors, processes, and systems issues.
Please forward comments and suggestions to the editor at:

Another key in successfully transitioning to DoD Patient Safety Center

Armed Forces Institute of Pathology
proactive risk assessment is providing per- 1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
sonnel resources to work patient safety Phone: 301-295-8115 • Fax: 301-295-7217
endeavors. Thirty-one contractors were E-Mail: patientsafety@afip.osd.mil • Website:http://patientsafety.ha.osd.mil
E-Mail to editor: poetgen@aol.com
hired and are working as program man-
agers, program assistants, and data ana- DIVISION DIRECTOR, PATIENT SAFETY PROGRAM: CAPT Deborah McKay
DIRECTOR, PATIENT SAFETY CENTER: Geoffrey Rake, M.D.
lysts. SERVICE REPRESENTATIVES:
ARMY: LTC Steven Grimes
Medical Team Management (MTM) is a NAVY: Ms. Carmen Birk
AIR FORCE: Lt Col Beth Kohsin
major undertaking by the Air Force. MTM PATIENT SAFETY BULLETIN EDITOR: Phyllis M. Oetgen, JD, MSW
teaches the basics of effective communica-