sábado, 2 de mayo de 2015

DoD Patient Safety Program Monthly eBulletin - May 2015

DoD Patient Safety Program Monthly eBulletin - May 2015

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The DoD Patient Safety Program eBulletin delivers patient safety updates, news, useful tips and resources. This month’s issue spotlights the importance of reporting to drive performance improvement in patient safety across the Military Health System. You can also check out a Patient Safety Awareness Week 2015 success story, a very important CE update, a Sentinel Event Spotlight and much more. Enjoy!



  • In May, the Military Health System will focus on Mental Health. Learn more.
  • Big Continuing Education news is coming your way! Be on the know:
  • Save the date for the 2015 TeamSTEPPS® National Conference in Denver, Colorado 16-18 June. Learn more.
  • Access the TEAM UP brochure – a starting point for engaging patients as part of a care team.
  • Access the DoD PSP’s the Medical Team Performance Assessment Tool (MTPAT) – a software application that supports the transition and sustainment of TeamSTEPPS®.
  • Check out the Patient Safety Learning Center– a member-based Patient Safety Community whre you can ccess and share knowledge about patient safety, and collaborate on best practices across the MHS.
  • The 17th Annual NPSF Patient Safety Congress hosted by the National Patient Safety Foundation is taking place right around the corner. Learn more.
  • Register for the May TeamSTEPPS® webinar “I-PASS: Integrating High Quality Handoffs into TeamSTEPPS® and Hospital Care” here.
  • Featured DoD PSP Toolkit: Debriefs.
  • Talk to us! Do you have an update from your facility? Let us know via email or Facebook.
Don’t forget to register for the May TeamSTEPPS® webinar ”I-PASS: Integrating High Quality Handoffs into TeamSTEPPS and Hospital Care” on Wednesday, May 13, 2015. Register now.

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. Stay tuned!

Feature: Reporting to Drive Performance Improvement in Patient Safety*

The goal of the DoD Patient Safety Program is to create a culture of patient safety and quality in the Military Health System. By encouraging a system’s approach to creating a safer patient environment that...Read more

A Patient Safety Awareness Week 2015 Highlight: Columbus Air Force Base – 14th Medical Group

The week of 8-14 March, 2015 was National Patient Safety Awareness Week. This year, just like we have done in the past, the DoD Patient Safety Program team invited Military Treatment Facilities CONUS and OCONUS to...Read more

Continuing Education Update: Announcing New CE Provider for Patient Safety Training Activities

Dear patient safety professionals across the Military Health System, please note that due to a change in their internal management model, Duke Office of Continuing Medical Education (DOCME) will be...Read more

TeamSTEPPS® Continuing Education Course Planning Checklist

When planning TeamSTEPPS Train the Trainer and Train the Staff activities, there are several accreditation requirements that must be met in order for attendees to be...Read more

Webinar Spotlight: I-PASS: Integrating High Quality Handoffs into TeamSTEPPS and Hospital Care

A few years ago, the I-PASS Study – which aims to improve safety by standardizing provider communication, particularly during transitions in care – was launched in response to...Read more

Sentinel Event Spotlight: URFO: Surgical Drains

This Sentinel Event Spotlight will focus on sentinel events within the MHS related to the retention of foreign objects caused by...Read more

PSR Data Pulse Update

Released on the 16th of every month, this report offers a snapshot of PSR events reported. This one page document provides a...Read more

Upcoming Events

Attention! Effective 30 June, 2015, the Postgraduate Institute for Medicine (PIM) will begin 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

I-PASS: Integrating High Quality Handoffs into TeamSTEPPS and Hospital Care Agency for Healthcare Research and Quality
13 May, 2015 from 1:00 p.m. to 2:00 p.m. EST
In this free AHRQ webinar, Christopher Landrigan, MD, MPH, Research Director of the Inpatient Pediatrics Service at Boston Children's Hospital and Associate Professor of Medicine and Pediatrics at Harvard Medical School, will be joined by Army Col. Clifton Yu, MD, Director of Medical Education at the Walter Reed National Mil­itary Medical Center. They will present their work on the I-PASS study, which aims to improve safety by standardizing provider communication, particularly during transitions in care. Drs. Landrigan and Yu serve as lead investigators in this project. Their presentation will seek to:
  • Review the literature on handoffs, miscommunications and patient safety.
  • Describe I-PASS, a bundle of handoff interventions inspired and informed by the TeamSTEPPS program.
  • Discuss the results of a multi-center study that implemented I-PASS in nine North American hospitals.

From Med Wreck to Med Rec: Results, Lessons Learned, and Implications from the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS) – National Patient Safety Foundation**
26 May, 2015 from 2:00 p.m. to 3:00 p.m. EST
This NPSF webinar will inform learners about a multi-centered study designed to improve medication reconciliation processes, including components of a quality improvement toolkit, quantitative results of the study, lessons learned for successful implementation, and implications and next steps for hospitals, health systems, and national patient safety leaders who wish to improve medication safety during transitions of care. This presentation will seek to:
  • Identify the components of the MARQUIS toolkit, designed to help hospitals improve their medication reconciliation processes
  • Appreciate the final results of the MARQUIS study in order to understand the effects of a mentored quality improvement intervention on medication reconciliation errors
  • Appreciate barriers and facilitators of implementation of the toolkit and the implications for hospitals and health systems that wish to improve their medication reconciliation efforts
  • List lessons learned from the sites that implemented the MARQUIS program and how they might be applied nationally
  • Explore the broader implications of the study in terms of EHR design, policy, regulation, and professional education.
Featured Speaker: 
Jeffrey L. Schnipper, MD, MPH, FHM
Director of Clinical Research, BWH Hospitalist Service
Associate Physician, Division of General Medicine, Brigham and Women's Hospital
Co-Chair, Partners Clinical Performance: Transitions in Care
Associate Professor of Medicine, Harvard Medical School

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 eLearning 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.
Register now

On-Demand eLearning: 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.
Register now

On-Demand eLearning: 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.
Register now

*Denotes that activity is CE-eligible. All CE credits are managed by Duke University Office of Continuing Medical Education.

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DoD Patient Safety Program • 7700 Arlington Blvd • Falls Church, VA 22042
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