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, our feature article highlights the critical connection between the learning organization concept and high reliability. In June, we are also spotlighting the Oro 2.0 High Reliability Maturity Assessment pilot study and we proudly congratulate the U.S Naval Hospital, Guam team for receiving the Stand Up for Patient Safety Management Award. Enjoy!
Announcements/Reminders
- In June, the Military Health System's theme is Men’s Health.
- Do you have questions about the Continuing Education process? We can help! Email us.
- The National Patient Safety Foundation (NPSF) has moved. >>Learn more.
- Talk to us! Do you have an update from your facility? Let us know via email or on Facebook.
Feature: The Military Health System as a Learning Organization
As the MHS continues its path toward high reliability, the term “learning organization” will become part of our collective lexicon as well as an integral part of our mindset as an…Feature: The Military Health System as a Learning Organization Page.
Patient Safety in Action: U.S Naval Hospital Guam is Selected as a 2016 Stand Up for Patient Safety Program Management Award Winner
The DoD Patient Safety Program congratulates U.S Naval Hospital (USNH) Guam , for receiving the National Patient Safety Foundation (NPSF)’s 2016 Stand Up for Patient Safety Management Award! Proudly representing the Military Health System (MHS), USNH Guam, received this prestigious accolade for…Patient Safety in Action: U.S Naval Hospital Guam is Selected as a 2016 Stand Up for Patient Safety Program Management Award Winner Page.
HRO Corner: The Oro™ 2.0 High Reliability Organizational Maturity Pilot Program and the Military Health System
Achieving a cultural transformation across the Military Health System (MHS) toward high reliability requires a mindset that aligns our individual and organizational actions with our vision for…HRO Corner: The Oro™ 2.0 High Reliability Organizational Maturity Pilot Program and the Military Health System Page.
DoD PSP Treasure Chest: June Edition
Welcome to the June 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: June Edition Page.
MHS Patient Safety Data Snapshot
The new MHS Patient Safety Data Snapshot is a monthly compilation of two types of patient safety data 1) Sentinel Event (SE) notifications submitted to the Patient Safety Analysis Center (PSAC); 2) Anonymous, voluntarily reported patient safety events via…MHS Patient Safety Data Snapshot Page.
MHS Patient Safety Spotlight
The MHS Patient Safety Spotlight is a new resource designed to highlight best practices and interesting initiatives that come from the field and are…MHS Patient Safety Spotlight Page.
Upcoming Events
Patient Safety Learning Circles
In-person or Web-based forums focused on a specific topic
2015 Quality and Patient Safety Award Winners – DoD Patient Safety Program
June 16, 2016 from 1:00 p.m. to 2:30 p.m. (ET)
This learning circle will provide the opportunity for four of the 2015 Quality and Patient Safety award winners to share highlights and lessons learned from their winning initiatives.
Presentation #1: Reduce Opiate Use in Chronic Pain Patient, presented by Evans Army Community Hospital.
Presentation #2: Implementation of a Rapid Response System - Evaluating the Effect on Rapid Response Activation and Code Rater, presented by Brooke Army Medical Center.
Presentation #3: Pediatric Dosing Calculator, presented by San Antonio Military Medical Center.
Presentation #4: Military Treatment Facility General Surgery NSQIP Colon Enhanced Recovery Proposal, presented by Fort Belvoir Community Hospital.
Visit the 2015 Quality and Patient Safety Award Winners Registration Page.
Using a Patient Safety Organization to Build an Even Safer Health Care System – National Patient Safety Foundation (NPSF)**
June 23, 2016 from 1:00 p.m. to 2:00 p.m. (ET)
Many health care providers and organizations practice in silos, without meaningful connections and information exchange with other health care entities to develop peer benchmarking and best practices. The Patient Safety Act breaks the silos and provides necessary confidentiality and privilege protections that permit the sharing of quality data and lessons learned, which may not otherwise be developed to positively influence the behavior and decisions of the providers for the benefit of patients. The PSES can be used as a tool to help maximize integration and patient care. This presentation will provide insight into how a provider and PSO can use a PSES to improve the quality of care in every healthcare organization across the nation.
Learning Objectives:
- Discover the benefits of working with a Patient Safety Organization, including best practices.
- Learn how to meet the requirements of section 1311(h) of the Affordable Care Act and the Merit-Based Incentive Payment System (MIPS).
- Create a learning system to prevent the same mistakes from being repeated by other health care professionals.
- Learn to use a Patient Safety Evaluation System (PSES) with integrated care models and new quality performance data tools.
- Use a PSES to create high-reliability in health care.
Featured Speakers:
- Lisa Mead
Executive Director
Strategic Radiology Patient Safety Organization
- Peggy Binzer
Executive Director
Alliance for Quality Improvement and Patient Safety
Visit the Using a Patient Safety Organization to Build an Even Safer Health Care System Registration Page.
TeamSTEPPS® Webinar – Agency for Healthcare Research and Quality (AHRQ)
July 13, 2016 from 1:00 p.m. to 2:00 p.m. (ET)
More details coming soon. Please check the TeamSTEPPS National Implementation website’s Webinars and Conferences section and our Calendar of Events for registration updates.
Medical Errors at the End of Life and Strategies for Improving Patient-Provider Communication – National Patient Safety Foundation (NPSF)**
July 20, 2016 from 1:00 p.m. to 2:00 p.m. (ET)
The focus of this webcast will be on failure to recognize patient preference at the end of life as a medical error and best practices for improving patient/provider communication.
Featured Speaker:
- Diane E. Meier, MD, FACP
Director
Center to Advance Palliative Care
Visit the Medical Errors at the End of Life and Strategies for Improving Patient-Provider Communication 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 MHS Learn.
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.