The DoD Patient Safety Program eBulletin delivers patient safety updates, news, useful tips and resources. This month’s issue provides an update on key Military Health System 90-Day Review-related efforts currently underway across the enterprise, a Continuing Education update and our latest Focused Review. In addition, we invite you to check out our brand new sections: “Patient Safety Spotlight” highlighting the JB Elmendorf-Richardson Patient Safety Program and the new “High Reliability Organization (HRO) Corner” – a section that focuses on high reliability best practices and patient safety-focused examples applicable to what you do on a daily basis to keep your patient safe. Enjoy!
Announcements/Reminders
The DoD PSP will continue to offer ongoing learning activities throughout 2015 and will advertise them via the DoD PSP eBulletin, the DoD PSP Calendar of Events and Facebook. We look forward to your participation in these events!
Feature: Update on Patient Safety Efforts Related to the Military Health System Review and High Reliability
The Military Health System has always been committed to continuous improvement and the delivery of the highest quality of care to…Feature: Update on Patient Safety Efforts Related to the Military Health System Review and High Reliability Page.
Patient Safety Spotlight: 673 Medical Group, Joint Base Elmendorf-Richardson, Alaska – Talk to Me: Reducing Issues Related to Communication Initiative
The DoD PSP team is thrilled to celebrate the outstanding efforts of the 673 Medical Group, Joint Base Elmendorf-Richardson Patient Safety Program! In June of 2015, a TeamSTEPPS® improvement project submitted by…Patient Safety Spotlight: 673 Medical Group, Joint Base Elmendorf-Richardson, Alaska – Talk to Me: Reducing Issues Related to Communication Initiative Page.
HRO Corner: High Reliability Organization Principles and the Military Health System
The DoD PSP team is excited to introduce the new HRO Corner section in our eBulletin! As the MHS continues its path toward becoming a High Reliability Organization, our team will…HRO Corner: High Reliability Organization Principles and the Military Health System Page.
Continuing Education Update: Online Registration Center Instructor Guidance
The Continuing Education team recently updated the Online Registration Center Instructor Guidance. Now, Course Coordinators have an…Continuing Education Update: Online Registration Center Instructor Guidance Page.
Sentinel Event Spotlight: Unintended Retained Foreign Object – Dental
This Sentinel Event Spotlight will focus on sentinel events within the MHS related to retained foreign objects in the…Sentinel Event Spotlight: Unintended Retained Foreign Object – Dental Page.
Focused Review: Patient and Family Engagement
Providing patient-centered care and fostering patient and family engagement leads to improved outcomes of care. The MHS, in its path to…Focused Review: Patient and Family Engagement Page.
PSR Data Pulse
Released on the 16th of every month, this report offers a snapshot of PSR events reported. This one page document should…PSR Data Pulse Page.
Upcoming Events
Attention! Effective June 30, 2015, the Postgraduate Institute for Medicine (PIM) will began accreditation for patient safety activities across the MHS. Learn more.
Patient Safety Learning Circles
In-person or Web-based forums focused on a specific topic
Health IT Safety Center Webinar Series – The Office of the National Coordinator for Health Information Technology
December 2014 through December 2015
This is a series covering a wide range of patient safety topics and will feature prominent quality and patient safety experts from across the U.S. Do not miss out!
Visit the Health IT Safety Center Webinar Series – The Office of the National Coordinator for Health Information Technology Registration page.
Addressing Behaviors that Undermine a Culture of Safety, Reliability and Accountability – Agency for Healthcare Research and Quality
September 9, 2015: 1:00pm - 2:00pm EDT
AHRQ is hosting a complimentary webinar on Wednesday, September 9 from 1 to 2 p.m. ET on the use of the agency's teamwork training program, TeamSTEPPS. Gerald B. Hickson, MD, who serves as the Senior Vice President for Quality, Safety and Risk Prevention, and Assistant Vice Chancellor for Health Affairs at Vanderbilt University Medical Center will focus on the issue of and challenges associated with team members whose behaviors undermine a culture of safety. Specifically, the presentation will seek to:
- Use a specific example of a team member's lack of compliance to illustrate a critical challenge with quality improvement interventions
- Describe the consequences of failure to address undermining behaviors
- Discuss strategies for addressing undermining behaviors
- Discuss the importance of teamwork in compliance and the sustainment of a culture of safety, reliability and accountability
Visit the Addressing Behaviors that Undermine a Culture of Safety, Reliability and Accountability – Agency for Healthcare Research and Quality Registration page.
Overuse of Health Care: Patient Safety Implications National Patient Safety Foundation**
September 16, 2015; 1:00pm - 2:00pm EDT
Learning Objectives:
- Recognize the potential risk of patient harm from overuse of tests, procedures, medication, physician visits, and hospitalization.
- Identify potential instances of overuse in clinical practices and institutions and become sensitized to its prevalence.
- Increase awareness of the potential for patient harm from overuse through discussions with colleagues and patients.
Featured Speaker:
Shannon Brownlee
Senior Vice President
Lown Institute
Visit the Overuse of Health Care: Patient Safety Implications National Patient Safety Foundation Registration page.
Patient Safety Workshops
Instructor-led or self-paced online learning sessions focused on a specific product
Attention! As part of the transition to the new CE provider, the Postgraduate Institute of Medicine, registrants who take enduring (non-live) training activities will be required to pass a CE test at the end of the activity.
Currently affected courses include on-demand eLearning (Patient Safety Reporting System v1.1 e-Learning Course and Patient Safety Reporting: Intermediate Course) and Focused Reviews.
Until this requirement is resolved and processes established for this new requirement, those courses will be ineligible for CE credit. Certificates of completion (non-CE credit) will still be available for registrants who complete those activities.
Please stay tuned for further updates on this matter.
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. Attention! Effective 30 June, 2015, the Postgraduate Institute for Medicine (PIM) began accreditation for patient safety activities across the MHS. Learn more)
**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
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