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Patient Safety

There are many factors the MHS tracks related to Patient Safety. For your convenience we have categorized these in the below sections:

Sentinel Events in the Military Health System

We encourage our medical staffs to report all types of patient safety events – injuries, illnesses and especially deaths. Sentinel events are those that result in harm to a patient and that require immediate reporting, response and investigation. More reported events don’t necessarily mean more events have occurred. It could mean that more providers have reported events. This measure is a system-wide one that gives you a snapshot of what kind of sentinel events the entire system reported in 2014 and 2015. Last Updated May 9, 2017.

Download the Report

What do we measure?

In 2015, the Military Health System (MHS) changed its policy to expand what types of sentinel events had to be reported. We identify those events that caused patient harm and report them across the entire MHS. This allows us to find ways to reduce risks and avoid harming our patients. Patient and families are partners in safer care.  If you or a family member sees or feels anything is unsafe or confusing, let us know right away.  Health care is complex, and we all have to work together for safe, effective care.

How do I read the results?

When you open the file, you will see a list of different types of sentinel events that occurred in military hospitals during 2014 and 2015. If you see an asterisk instead of a number next to an event type, that means there was at least one event of that type, but too few events to report without endangering patient privacy.

Sentinel Events by Military Hospital

We encourage our medical staffs to report all types of patient safety events – injuries, illnesses and especially deaths. Sentinel events are those that result in harm to a patient and that require immediate reporting, response and investigation. More reported events don’t necessarily mean more events have occurred.  It could mean that more providers have reported events. This measure is a facility-specific one that shows you what sentinel events occurred in individual hospitals or clinics. Last Updated May 9, 2017.

Download the Report

What do we measure?

In 2015, the MHS changed its policy to expand what types of sentinel events had to be reported. We identify those events that caused patient harm and report them across the entire MHS. This allows us to find ways to reduce risks and avoid harming our patients. Patient and families are partners in safer care.  If you or a family member sees or feels anything is unsafe or confusing, let us know right away.  Health care is complex, and we all have to work together for safe, effective care.

How do I read the results?

When you open the file, you will see a list of military hospitals and clinics in the left column. Below each will be an description of the types of sentinel events that were reported by that facility. If you see an asterisk instead of a number next to an event type, that means there was at least one event, but too few to report without endangering patient privacy. If a hospital or clinic is not listed, it did not report any sentinel events in 2014 or 2015.

Patient Safety Event Reporting

You expect us to keep you safe when you are in one of our hospitals or clinics. One way we do that is by reporting and reviewing Patient Safety Events so we can identify and fix potentially unsafe conditions in our hospitals and clinics. Patient Safety Events are any avoidable event that could result in harm to a patient. This includes what we call "near miss" events where a patient isn't harmed, but could have been. Visit the Patient Safety Reporting page for the report.

What do we measure?

All facilities in the MHS Direct CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”Direct Care System voluntarily report their patient safety events to the MHS Patient Safety Program. Unlike most other health systems, we also report events in our dental program because the MHS integrates dental into its medical system.

How do I read the results?

Visit the Patient Safety Event Reporting page to see the report from Fiscal Year 2014. This will be updated with Fiscal Year 2015 information in the near future.

Catheter-Associated Urinary Tract Infection in the ICU

A catheter is a drainage tube that is inserted by a doctor into a patient’s urinary bladder through the urethra and is left in place to collect urine while a patient is immobile or incontinent. When not put in correctly or kept clean, or if left in place for long periods of time, catheters can become an easy way for germs to enter the body and cause serious infections in the urinary tract. These infections are called catheter-associated urinary tract infections (CAUTIs), and they can cause additional illness or be deadly. CAUTIs are mostly preventable when healthcare providers use infection control steps recommended by the Centers for Disease Control and Prevention (CDC). Last Updated May 9, 2017.

Download the Report

What do we measure?

We track the number of infections developed by patients in the ICU because of catheter-associated urinary tract infections. We look at the number of infections compared to the number of expected infections based on the number of patients who had catheters during the time frame being measured. You and your family should ask about our processes for preventing infections.  You are encouraged to be proactive with your care team and ask for catheters to be removed at the earliest possible time that it can be safely removed.

How do I read the results?

When you open the file you will see a list of military hospitals and clinics in the left column and a score for how well the facility performed on the measure during 2014 and the four quarters of 2015. The ratings are reported against a national benchmark for the patient population of the facility, showing those that are better than the benchmark, those that are no different than the benchmark, and those that are worse than the benchmark, or in some cases a report of zero events. If you see an asterisk instead of a rating or a report of zero events, that means that the hospital had too small a number of patients to calculate a score.

Central Line Associated Blood Stream Infection in the ICU

A central line is a narrow tube inserted by a doctor into a large vein of a patient’s neck or chest to give important medical treatment. For patients in the ICU, a central-line is often necessary so the patient can receive fluids and medication. When not put in correctly or kept clean, central lines can become an easy way for germs to enter the body and cause serious infections in the blood. These infections are called central line-associated bloodstream infections (CLABSIs), and they can be deadly. CLABSIs are mostly preventable when healthcare providers use infection control steps recommended by the Centers for Disease Control and Prevention (CDC). Although a 46% decrease in CLABSIs has occurred in U.S. hospitals between 2008-2013, an estimated 30,100 CLABSIs still occur in intensive care units and acute care facilities each year. Last Updated May 9, 2017.

Download the Report

What do we measure?

We track the number of infections developed by patients in the ICU because of central-line devices. We study our infection rates by line days --- the number of infections divided by the number of line days (number of patients in a day with at least one central line). The rate is the number of occurrences per 1,000 line days. You and your family should ask about our processes for preventing infections. You are encouraged to be proactive with your care team and ask for the central lines to be removed at the earliest possible time that it can be safely removed.

How do I read the results?

When you open the file, you will see a list of military hospitals and clinics in the left column and a score for how well the facility performed on the measure during 2014 and the four quarters of 2015. The ratings are reported against a national benchmark for the patient population of the facility, showing those that are better than the benchmark, those that are no different than the benchmark, and those that are worse than the benchmark, and in some cases when no events occurred in a facility. We are only allowed by law to report events when the number reaches a certain threshold. If you see an asterisk instead of a rating or a report of zero events, that means that the hospital had too small a number of patients to calculate a score.

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Catheter and Central Line Infections in Military Hospitals

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5/9/2017

A catheter is a drainage tube that is inserted by a doctor into a patient’s urinary bladder through the urethra and is left in place to collect urine while a patient is immobile or incontinent. When not put in correctly or kept clean, or if left in place for long periods of time, catheters can become an easy way for germs to enter the body and cause ...

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Sentinel Events Across the MHS

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5/9/2017

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Sentinel Events by Military Hospital

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5/9/2017

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DHA PI Number 6025.01: Implementing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) across the Military Health System (MHS)

Policy

This Defense Health Agency-Procedural Instruction (DHA-PI) assigns responsibilities and establishes uniform guidelines, standards, and procedures for all DoD Medical Treatment Facilities (MTFs) providing healthcare services in the direct care system to implement the surgical quality and reporting guidelines developed by ACS NSQIP, as well as DoD procedural requirements.

Central Line Infections in Military Hospitals

Report
10/7/2016

A central line is a narrow tube inserted by a doctor into a large vein of a patient’s neck or chest to give important medical treatment. For patients in the ICU, a central-line is often necessary so the patient can receive fluids and medication. When not put in correctly or kept clean, central lines can become an easy way for germs to enter the body ...

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Catheter Infections in Military Hospitals

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10/7/2016

A catheter is a drainage tube that is inserted by a doctor into a patient’s urinary bladder through the urethra and is left in place to collect urine while a patient is immobile or incontinent. When not put in correctly or kept clean, or if left in place for long periods of time, catheters can become an easy way for germs to enter the body and cause ...

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Brooke Army Medical Center Transparency

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7/28/2016
Brooke Army Medical Center Transparency

This video highlights Brooke Army Medical Center's transparency initiatives and what they are doing to publish information about Patient Safety, Health Outcomes, Quality of Care and Patient Satisfaction.

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DoD Instruction 6025.13: Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS) Instruction

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This Department of Defense Instruction (Number 6025.13) establishes DoD policy on issues related to MQA programs and clinical quality management activities.

Good Catch Recognition Award Process

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This memorandum describes the annual Navy Medicine "Surgeon General Good Catch Annual Recognition Award". A "Good Catch" signifies a near miss, unsafe condition, or error(s) (environmental, IT, process, system design) that was identified early to prevent and/or minimize preventable harm to patients.

Sentinel Events by Military Hospital

Report
5/20/2016

We encourage our medical staffs to report all types of patient safety events – injuries, illnesses and especially deaths. Sentinel events are those that result in harm to a patient and that require immediate resporting, response and investigation. More reported events don’t necessarily mean more events have occurred. It could mean that more providers ...

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Sentinel Events Across the MHS

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5/20/2016

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Trusted Care – Patient Centeredness Vision

Policy

This memorandum from the Air Force Surgeon General describes the "Patient Centeredness Vision" which encompasses the six aims of health care: safe, effective, patient centered, timely, efficient, and equitable.

Management and Reporting of Clinical Adverse Actions and Professional Misconduct for Privileged Health Care Providers and Non-Privileged Clinical Support Staff

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The purpose of this directive is to update and establish policy, assign responsibility, and prescribe procedures for the management and reporting of clinical adverse actions and professional misconduct for privileged health care providers and non-privileged clinical support staff for the Department of the Navy.

Surgical Pause Standard Operating Procedure

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The purpose of this memorandum is to provide guidance to perioperative personnel involved in surgical care including Labor and Delivery in conducting and documenting a Surgical Pause during invasive procedures.

Prevention of Retained Surgical Items Standard Operation Procedure

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The purpose ofthis memorandum is to provide guidance to perioperative personnel for prevention ofunintended retained surgical items during operative or other invasive procedures.

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