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 spotlight the connection between leadership engagement and the Military Health System (MHS) path towards high reliability. We also invite you to check out articles on the Constancy of Purpose High Reliability Organization (HRO) principle, Patient Safety Awareness Week (PSAW) 2016 highlights from the field, and much more. Enjoy!
Announcements/Reminders
- In May, the Military Health System's theme is: Mental Health.
- Do you have questions about the Continuing Education process? We can help! Email us at pspcourses@bah.com.
- The 2016 TeamSTEPPS® National Conference will take place in Washington, D.C. in June. >>Learn more.
- Talk to us! Do you have an update from your facility? Let us know via email or on Facebook.
Feature: The Connection between Leadership Engagement and High Reliability
The Military Health System (MHS) path towards high reliability is paved by our collective focus to achieve the elimination of patient harm. Because of this, many efforts are presently underway to…Feature: The Connection between Leadership Engagement and High Reliability Page.
Patient Safety in Action: Patient Safety Awareness Week (PSAW) 2016 Highlights from the Field
The week of 13-19 March, 2016 was National Patient Safety Awareness Week (PSAW). This year, just like we have done in the past, the DoD PSP team invited Military Treatment Facilities (MTFs) across the Military Health System (MHS) to…Patient Safety in Action: Patient Safety Awareness Week (PSAW) 2016 Highlights from the Field Page.
HRO Corner: Understanding the Constancy of Purpose High Reliability Organization Guiding Principle
In May, we are taking an in-depth look at the Constancy of Purpose HRO principle and how it applies to what you do to keep your patients safe on a daily basis. Please read on…HRO Corner: Understanding the Constancy of Purpose High Reliability Organization Guiding Principle Page.
DoD PSP Treasure Chest: May Edition
Welcome to the May 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: May 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
Click the image to view/print a list of all upcoming patient safety activities.
Patient Safety Learning Circles
In-person or Web-based forums focused on a specific topic
Patient-Centered Fall Prevention – National Patient Safety Foundation (NPSF)**
May 11, 2016 from 2:00 p.m. to 3:00 p.m. (ET)
This webinar will describe the problem of patient falls in hospitals and the evidence related to fall prevention. The three-step fall prevention process will be reviewed along with strategies for engaging patients. A suite of tools for engaging patients in the three-step fall prevention process will also be demonstrated.
Learning Objectives:
- Describe the problem of patient falls.
- Review the evidence related to fall prevention in hospitals.
- Discuss the rationale for engaging patients in fall prevention efforts.
- Review available tools for engaging patients in the 3-step fall prevention process.
Featured Speaker:
- Patricia C. Dykes, PhD, RN, FAAN, FACMI
Senior Nurse Scientist
Program Director, Center for Patient Safety Research and Practice
Program Director, Center for Nursing Excellence
Brigham and Women's Hospital
Visit the Patient-Centered Fall Prevention Registration Page.
Enhancing Code Blue Team Effectiveness Leveraging TeamSTEPPS® – Agency for Healthcare Research and Quality (AHRQ)
May 11, 2016 from 1:00 p.m. to 2:00 p.m. (ET)
This webinar on the use of TeamSTEPPS to enhance the effectiveness of Code Blue team leadership at Christiana Care Health System in Wilmington, Delaware. The session will feature multiple staff from the Christiana Care system. Their presentation will focus on the development and implementation of a training curriculum for Code Blue team leaders, who can lead and shape expected team behaviors through the use of TeamSTEPPS tools such as briefs, call-outs, check-backs and post-code debriefs.
Learning Objectives:
- Describe the development of a Code Blue team leader training curriculum that is designed to support clinical team effectiveness.
- Recognize the importance of a learning needs assessment prior to initiation of training to assess gaps and inform the curriculum design.
- Explain the value of post-code team debriefs for continuous improvement.
Featured Speakers:
- Susan Coffey-Zern, MD, CHSE
Director of Virtual Education and Simulation Training
- Michael Vest, DO, FACP, FCCP
Pulmonary and Critical Care Medicine
- Loretta Consiglio-Ward, MSN, RN
Quality/Safety Education Specialist
- Carol Kerrigan Moore, MS, FNP-BC
Quality/Safety Education Specialist
Visit the Enhancing Code Blue Team Effectiveness Leveraging TeamSTEPPS® Registration Page.
2015 Quality and Patient Safety Award Winners – DoD Patient Safety Program
May 19, 2016 from 1:00 p.m. to 2:00 p.m. (ET)
This Learning Circle will feature presentations from two of the 2015 Quality and Patient Safety Awards winners. The topics covered will be: "Outcome of Pediatric Inpatient Asthma Clinical Pathway Implementation in a Military Medical Center" and "The Effectiveness of Interventions to Increase Provider Monitoring of Endotracheal Tube and Laryngeal Mask Airway Cuff Pressures.“
Featured Presenters:
- San Antonio Military Medical Center
- Naval Medical Center San Diego
Visit the 2015 Quality and Patient Safety Award Winners Registration Page.
CAUTI Prevention in the Trenches: Because Bundles Don’t Implement Themselves
CAUTI Affinity Group Spring Special Learning Event – Partnership for Patients (PfP) 2.0
May 23, 2016 from 2:00 p.m. to 3:30 p.m. (ET)
In a continued movement to reduce device utilization and hospital associated Catheter-Associated Urinary Tract Infections (CAUTI), the PfP 2.0 CAUTI Affinity Group is hosting a special 90 minute Spring Special Learning Event for all HENs and their hospitals.
This event will feature numerous examples of successful methods to engage and empower the frontline and support the culture change needed to sustain best practice implementations for significant strides in device utilization reduction and CAUTI prevention.
Learning Objectives:
- Better understand how to change the culture at the bedside
- How to identify and engage champions within your facility
- Proven successful strategies to reduce device utilization (targeting Emergency Departments and ICU)
- How to engage physicians in the culture change
- Patient engagement strategies
- Explore creative alternatives to indwelling urinary catheters
- Gain tips for successful implementation of Nurse Driven Protocols for Bladder Management
- Obtain ready-to-use tools created by successful healthcare organizations
- Tools for bedside auditing
- Tools to identify opportunities for improvement
- Tools to share with stakeholders
Visit the CAUTI Prevention in the Trenches: Because Bundles Don’t Implement Themselves Registration Page.
Lessons Learned from Patient Safety Organizations – National Patient Safety Foundation (NPSF)**
June 23, 2016 from 1:00 p.m. to 2:00 p.m. (ET)
More details coming soon. Please check the NPSF website’s “Upcoming Webinars” 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)
More details coming soon. Please check the NPSF website’s “Upcoming Webinars” section and our Calendar of Events for registration updates.
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.