viernes, 2 de septiembre de 2016

DoD Patient Safety Program Monthly eBulletin - September 2016

DoD PSP Patient Safety Monthly eBulletin September 2016

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 surgical improvement efforts across the MHS such as the National Surgical Quality Improvement Program (NSQIP®), the 2016 Advancement toward High Reliability in Healthcare Awards Program and much more. Enjoy!



  • In September, the Military Health System's theme is Healthy Aging: Learn more.
  • NEW Did you hear?! The RCA Resource Guide was recently released! Check it out.
  • Do you have questions about the Continuing Education process? We can help! Email us
  • NEW It's here! The Unintended Retained Foreign Objects (URFOs) Guidebook is here! Access this resource today.
  • Talk to us! Do you have an update from your facility? Let us know via email or Facebook.

Feature: Surgical Quality Improvement and High Reliability across the Military Health System

In May of 2015, in response to the MHS 90-Day Review action item requiring the expansion of participation in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP®) by inpatient military treatment facilities, the Defense Health Agency (DHA) hosted a three-day collaborative meeting which included surgical quality representatives (Surgeon Champions and Surgical Clinical Reviewers (SCRs) from each of the Services and the National Capital Region Medical Directorate (NCR MD))...Read more

Patient Safety in Action: The Department of Defense Makes its Mark at the 2016 National Surgical Quality Improvement Program Conference

The NSQIP expansion across the MHS is a collaborative of subject matter experts (SMEs) and surgical leadership from participating military treatment facilities (MTFs) sponsored by Office of the Assistant Secretary of Defense/Health Affairs (OASD/HA) and the Defense Health Agency (DHA). At the July 2016 American College of Surgeons Association National Surgical Quality Improvement Program NSQIP Annual Conference in San Diego, CA, two breakout were conducted to discuss NSQIP enrollment and expansion progress to date across the Military Health System (MHS) as well as to provide guidance on the implementation and strategic goals of NSQIP in the Direct Care system...Read more

HRO Corner: Experts and Resources Advance Surgical Quality and Improvement across the Military Health System

Improving patient safety and quality by proactively preventing patient harm and ensuring our service members’ medical readiness is of utmost importance for leadership and staff across the Military Health System (MHS). For this reason, and in response to the MHS 90-Day Review in May of 2015, the MHS is currently engaged in the expansion of participation in the American College of Surgeons (ACS) NSQIP to inpatient military treatment facilities (MTFs)...Read more

Update: Advancement toward High Reliability in Healthcare Awards Program

The Advancement toward High Reliability in Healthcare Awards Program (Awards) recognizes Department of Defense (DoD) staff who have shown initiative and commitment to the development of systems and processes that will transform the Military Health System (MHS) into a high reliability organization (HRO) and ensure that we partner with patients every step of the way...Read more

DoD PSP Treasure Chest: September Edition

Welcome to the September 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 tools and information developed with you, our committed MHS patient safety champions, in mind...Read more

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 the web-based incident reporting system known as PSR...Read more

MHS Patient Safety Spotlight

The MHS Patient Safety Spotlight is a resource designed to highlight best practices and interesting initiatives that come from the field and are worthy of being shared across the enterprise. This resource features data-driven examples of improvement and case studies that tackle specific problems with specific solutions...Read more

Upcoming Events

Learning Update September October 2016 Click the image above to automatically download a copy of all upcoming patient safety events, or click the link to view a list of all upcoming patient safety events:  

Patient Safety Learning Circles:
In-person or web-based forums focused on a specific topic
Agency for Healthcare Research and Quality (AHRQ) LogoTeamSTEPPS Webinar – Agency for Healthcare Research and Quality (AHRQ)
Please check our Calendar of Events for updates on this webinar.

Health Literacy: Improving Patient Understanding – National Patient Safety Foundation (NPSF)**
27 September, 2016 from 1:00pm to 2:00pm ET
National Patient Safety Foundation (NPSF) Logo
Join this NPSF webinar to learn about the challenges that patients have understanding healthcare information. For instance, did you know that health literacy affects some patients more than others? This webinar will address the risk factors that can potentially limit a patient's understanding and behaviors associated with limited health literacy. Oral and written communication strategies to address this problem will be discussed along with three health literacy tools developed by the Pennsylvania Patient Safety Authority.
Learning Objectives:
  • ­Identify risk factors that can influence a patient’s ability to process and understand healthcare information
  • Describe behaviors that patients with low health literacy levels may exhibit
  • Plan an approach to implementing oral and written health literacy communication strategies
Featured Speaker:
  • Lea Anne Gardner, MSPH, PhD, RN
    Senior Patient Safety Analyst
    Pennsylvania Patient Safety Authority

Implementing RCA2: Lessons from the Trenches: Aurora Health Care – National Patient Safety Foundation (NPSF)**
4 October, 2016 from 1:00pm to 2:00pm ET
National Patient Safety Foundation (NPSF) Logo
This special series of complimentary webcasts, based on the NPSF report RCA2: Root Cause Analyses and Actions to Prevent Harm, will provide a deep-dive into implementation of the report’s tools and key recommendations through the lens of five organizations at various places on their root cause analysis improvement journeys.
The organizations, which range from large health systems to individual hospitals and academic medical centers, will share their stories of successful implementation of the RCA2 process and explore their experiences with barriers and challenges faced along the way.
The presentations will provide insight into topics that include:
  • Use of risk-based prioritization systems
  • Effectively engaging leadership
  • Setting up and maintaining RCA2 teams
  • Utilizing the tools in the report to determine, and follow up on, effective corrective actions

Patient Safety Workshops:
Instructor-led or self-paced online learning sessions focused on a specific product
On-Demand eLearning: Patient Safety Reporting System v1.01 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 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. 

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Patient Safety Reading Corner

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