The Department of Defense (DoD) Patient Safety Program (PSP) eBulletin delivers patient safety updates, news, useful tips, and resources to help you deliver the highest quality of care to your patients. This month, we highlight the Root Cause Analysis (RCA)/Sentinel Event (SE) reporting process and its connection to high reliability. You will also learn about the “Reluctance to Simplify” High Reliability Organization (HRO) principle and how it applies to what you do to keep your patients safe. We also invite you to check out our interview with Dr. Ashok Ramalingam, the new Chief of the Patient Safety Analysis Center (PSAC), and encourage you to access multiple tools and resources via our Patient Safety Treasure Chest. Enjoy!
Announcements/Reminders
- In April, the Military Health System's theme is: Children's Health.
- Share your Patient Safety Awareness Week 2016 MTF activities with us! Email us. We look forward to hearing from you!
- The 2016 TeamSTEPPS® National Conference will take place in Washington, D.C. in June. >>Learn more.
- Do you have questions about the Continuing Education process? We can help! Email us.
- Talk to us! Do you have an update from your facility? Let us know via email or on Facebook.
Feature: Root Cause Analysis (RCA) and Sentinel Event (SE) Reporting at the Heart of High Reliability
An important aspect of high reliability is maintaining a sense of collective mindfulness within the organization. Mindfulness to stay alert and deal with risk as it occurs and mindfulness to…Feature: Root Cause Analysis (RCA) and Sentinel Event (SE) Reporting at the Heart of High Reliability Page.
Patient Safety in Action: An Interview with Dr. Ashok Ramalingam, Chief of the Patient Safety Analysis Center (PSAC) – A Leadership Perspective
We recently interviewed Dr. Ashok Ramalingam, Ph.D., M.S, B.Pharm, D.Pharm, R.Ph, CPPS, and new Chief of the PSAC, to learn about his experience, background, perspectives on patient safety and how these factors set a standard for…Patient Safety in Action: An Interview with Dr. Ashok Ramalingam, Chief of the Patient Safety Analysis Center (PSAC) – A Leadership Perspective Page.
HRO Corner: Delving into the Reluctance to Simplify High Reliability Organization Guiding Principle
In April, we are delving into the Reluctance to Simplify High Reliability Organization (HRO) principle and how it applies to what you do to keep your patients safe on a daily basis. Please read on…HRO Corner: Delving into the Reluctance to Simplify High Reliability Organization Guiding Principle Page.
Announcing a New TeamSTEPPS® Course: TeamSTEPPS for Office-Based Care
TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) has been tailored for office-based health care providers and team members, and is now available online, through the Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS for Office-Based Care, is an…Announcing a New TeamSTEPPS® Course: TeamSTEPPS for Office-Based Care Page.
DoD PSP Treasure Chest: April Edition
Welcome to the April edition of the DoD PSP Treasure Chest! Each and every month, we will be sharing resources to help you execute your day-to-day patient safety activities easily and effectively. Please visit us often and get access to…DoD PSP Treasure Chest: April Edition Page.
Upcoming Events
Patient Safety Learning Circles
In-person or Web-based forums focused on a specific topic
Professional Learning Series Webcast: Implementing an Effective Communication and Resolution Program – National Patient Safety Foundation (NPSF)
April 5, 2016 from 1:00 p.m. to 2:00 p.m. (ET)
The NPSF is offering a complimentary webcast designed for the senior leaders of an organization, including members of the executive suite, board members and safety leaders. This webcast will provide a new way of thinking about transparency and disclosure. Through an in-depth look at Communication and Resolution Programs (CRPs), the facilitators will offer strategies organizations can adopt to improve communication both internally and externally following an adverse event. Participants will have opportunity to hear from multiple leaders in the field of medicine who have implemented successful CRPs. Objectives include:
- Describe how the current response to adverse events falls far short of best practices and the consequences for patients, providers, and healthcare institutions
- Recognize the five key elements of a CRPs and recap how a CRP could benefit you and your organization
- Discuss common pitfalls organizations experience while implementing a CRP and how to avoid them
- Identify resources to help your institution maximize the benefits and avoid the pitfalls associated with creating a high-functioning CRP
Visit the Professional Learning Series Webcast: Implementing an Effective Communication and Resolution Program Registration Page.
Using TeamSTEPPS to Reduce Patient Harm: Strategies and Successes across Multiple Settings – Agency for Healthcare Research and Quality (AHRQ)
April 13, 2016 from 1:00 p.m. to 2:00 p.m. (ET)
AHRQ is hosting a webinar on the implementation of TeamSTEPPS across facilities operated by the Healthcare Corporation of America (HCA). The webinar, "Using TeamSTEPPS to Reduce Patient Harm: Strategies and Successes across Multiple Settings," will feature Bill Laxton, RN, BSN, CPHRM, Director of the Risk and Patient Safety Department in the Clinical Services Group at HCA. His presentation will include HCA's history with TeamSTEPPS; lessons learned from over seven years of implementation and sustainment; and specific successes related to the reduction of patient harm. Specifically, the presentation will seek to:
- Provide an overview of HCA's work with TeamSTEPPS across multiple facilities and settings.
- Discuss some lessons learned through both successes and failures.
- Discuss the implementation of and results associated with specific TeamSTEPPS interventions that have been linked to reductions in patient harm in areas such as falls and retained foreign bodies.
Visit the Using TeamSTEPPS to Reduce Patient Harm: Strategies and Successes across Multiple Settings Registration Page.
Patient Safety Workshops
Instructor-led or self-paced online learning sessions focused on a specific product
On-Demand eLearning: Patient Safety Reporting System v1.1 e-Learning Course
This course introduces basic navigation and functionality features of the PSR system and the roles of system users, such as event reporters, event handlers, and investigators. The course can be accessed through the Joint Knowledge Online (JKO) Learning Management System (LMS).
Visit the eLearning Courses page to register for this course.
On-Demand e-Learning: Patient Safety Reporting: Intermediate Course*
Targeted to Patient Safety Managers and other MTF staff already familiar with basic functionalities of the Patient Safety Reporting System, this course is designed to help learners hone the decision-making skills needed to effectively manage patient safety event data in PSR, as part of the ongoing effort to eliminate preventable harm at MTFs.
Patient Safety Reporting: Intermediate Course Registration Page
On-Demand e-Learning: Root Cause Analysis*
This self-paced module outlines the Patient Safety Program’s suggested practices for conducting a root cause analysis, from the initial reporting of a patient safety event through the formation of the RCA Team to the identification of contributing factors and root causes and the recommendation of corrective actions.
Root Cause Analysis Course Registration Page
*Denotes that activity is eligible for CE credit. All CE credits are managed by the Postgraduate Institute for Medicine (PIM).
**Did you know? As an NPSF Stand Up for Patient Safety member, DoD PSP receives complimentary access to webinars as a benefit of program membership. Check with your facility POC to obtain the member coupon code.
Patient Safety Reading Corner
The following articles are external and for informational purposes only. The DoD does not sponsor these websites.