INSIDE: SERVICES OUTLINE PLANS FOR IHI COLLABORATION

FALL 2007 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

DOD FACILITIES JOIN

IHI 5 MILLION LIVES CAMPAIGN
Services Share Enthusiasm and Dedication to Improving Patient Safety

T
he Military Healthcare System has
embraced one of the most exciting
challenges available to improve
patient safety. It has formally joined the
Institute for Healthcare Improvement
(IHI) 5 Million Lives Campaign. Each Mil-
itary Treatment Facility (MTF) across the
three services is a full participant in this
nation-wide data-sharing initiative.
The 5 Million Lives Campaign builds on
the successful 100,000 Lives Campaign, in
which 3,100 participating hospitals
reduced inpatient deaths by an estimated
122,000 in eighteen months. While contin-
uing to fight preventable deaths, partici-
pants are now being called to expand their
focus to protecting patients from medical-
ly-induced harm. IHI has targeted twelve
proven interventions which US hospitals
are being asked to adopt to save lives and
reduce patient injuries (see blue box).
The Department of Defense Patient Safety
Program (DoD PSP) is coordinating the par-
ticipation of its MTFs through the direction
of TRICARE Quality Forum, Quality and
PSP Service Representatives. They are work-
ing closely with Patient Safety Managers,
facility leaders and providers as each Service
and MTF begins to implement its IHI part-
nership. While the Services vary in their
strategies, there is uniform agreement
among them that MTF staff have enthusias-
tically embraced this IHI challenge. glimpse of the spirit and commitment DoD
Response has been extraordinarily strong, providers are bringing to this dramatic,
creative and widespread. The following demanding challenge to further improve
examples from each Service provide a patient safety.
5 Million Lives Campaign Interventions
…from the 100,000 Lives Campaign
•Deploy Rapid Response Teams ...at first sign of patient decline
•Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction
•Prevent Adverse Drug Events (ADEs) ...by implementing medication
reconciliation
•Prevent Central Line Infections ...by implementing a series of inter-
dependent, scientifically grounded steps
•Prevent Surgical Site Infections ...by reliably delivering the correct
perioperative antibiotics...
•Prevent Ventilator-Associated Pneumonia ...by implementing a series
of interdependent, scientifically grounded steps
…new interventions targeted at harm
•Prevent Harm from High-Alert Medications ...starting with a focus on
anticoagulants, sedatives, narcotics, and insulin
•Reduce Surgical Complications
•Prevent Pressure ulcers
•Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection
•Deliver Reliable, Evidence-Based Care for Congestive Heart Failure
•Get Boards on Board

FALL 2007

5 PSC: Suicide Prevention

6 Army Dental Patient Safety
7 Microsystems Successes
5 MILLION LIVES
CAMPAIGN
Continued from Page 1
Air Force Establishes
Rapid Response Teams
The Air Force has chosen, as its initial IHI
collaborative, to adopt a uniform interven-
tion across its sixteen in-patient MTFs. All
facilities are in the process of deploying
Rapid Response Teams (RRT). PSP Manager,
Lt Col Kathryn Robinson, describes a great
deal of enthusiasm, despite special chal-
lenges for those facilities without ICUs. She
coordinates biweekly teleconferences among
staff and IHI consultants to facilitate the
teams’ successful implementation. Scott
Chittenden, RN, MA, CEN, PSP Manager,
374th Medical Group (MDG), Yokota Air
Base and Shelley Drake, BSN, MS, PSP Man-
ager, 99th MDG, Nellis Air Force Base share
their efforts to date:
374 Medical Group, Yokota Air Base
The 374th MDG, Yokota began its imple-
mentation planning by forming a “Change
Team” — a champion physician, a member
from the executive committee, an active duty
registered nurse, and the patient safety pro-
gram manager — to lead this project.
The Change Team assessed the current climate
and welcomed discussion about forming the
RRT. Physicians from the internal medicine
Pictured around the mannequin during RRT/Code Blue training are 374 MDG staff
members TSgt Juan Cortez (FP/UC 4N), A1C William Buell (FM, 4N), A1C Crystal Lun-
dahl (4N, Derm).
2 FALL 2007 PATIENT SAFETY
clinic, pediatrics, and family practice provided
input on developing criteria to be used by the
nurses to initiate a call to a rapid responder.
The criteria will be used for adult and pedi-
atric patients admitted to the Family Care
Unit. The project inspired the obstetrical med-
ical director to develop an Obstetrical Emer-
gency Response Team (OBERT). This project
will be under the direction of the OB Medical
Director with assistance from the Patient Safe-
ty Program Manager.
The hospital has a 24 hour, seven day a week
Urgent Care, staffed by one RN, three med-
ical technicians, and one family practice
physician. The Change Team developed a
robust RRT responder call roster by incorpo-
rating the in-house anesthesiologists during
day hours and the Urgent Care doctor in the
evening and early morning. RN and medical
technicians are the second responders and
are called by the RRT physician when indi-
cated. The Family Care Unit nurses and
attending physician are always incorporated
in the team, and the attending is always noti-
fied when an RRT call is made.
99 Medical Group, Nellis Air Force Base
The initiatives of IHI’s 5 Million Lives
Campaign are familiar to most clinicians at
the Mike O’Callaghan Federal Hospital,
home of the 99 MDG at Nellis AFB in Las
Vegas, Nevada. Multidisciplinary teams
comprised of staff from the Air Force and
our VA joint venture partners started
Maj James Pollock Nellis AFB physician
champion for IHI initiative will attend the
IHI National Conference in Orlando, FL in
early December, 2007 with ICU nurse
Capt Savneet Gill, a fellow RRT member.
Maj Pollock, a family practice physician is
”...honored to be selected and excited to
learn more about IHI and be an active
member of the IHI Team.”
implementing IHI bundles in the ICU as
long as two years ago. Membership in IHI
gives their work greater facility-wide visi-
bility and importance.
The time and experience-tested resources of
IHI, free on-line, were readily available, use-
ful guides as we began to implement the 2008
National Patient Safety Goal of the Rapid
Response Team (RRT). We easily modified an
IHI brochure to fit our facility. The brochure
and an introduction to the 5 Million Lives
Campaign are included in the patient safety
portion of our new employee orientation.
The collegial bi-weekly teleconferences
hosted by Lt Col Kathryn Robinson, Air
Force Patient Safety Program Manager and
IHI contact are extremely helpful. They
allow Nellis to share experiences and
progress with other MTFs with ICUs. As the
only Air Combat Command facility of our
size and complexity, working through the
process with our peers is energizing.
A physician and nurse champion, chosen for
their enthusiasm and dedication to quality
improvement, will attend the December
2007 IHI National Conference in Orlando in
addition to joining the IHI team.
With the dedicated cooperation of our VA
counterparts, the Rapid Response Team pol-
icy is written; team, staff, and patient educa-
tion materials are prepared; and evaluation
forms are ready for use. Our “go-live” date is
on target for February 2008.
Army Working Groups Develop
Policy from End-User Perspective
The Army Medical Department (AMEDD) is
currently developing policies related to four
IHI interventions — prevention of Ventilator-
Associated Pneumonia, Central Line Infec-
tions, and Harm from High Alert Medica-
tions, as well as deployment of Rapid
Response Teams. Employing a unique, and
highly successful, approach AMEDD is utiliz-
ing end-user working groups to draft the cor-
porate policies that will guide their IHI
involvement. The groups cross disciplines,
with providers, nurses, respiratory therapists
and patient safety managers represented from
among the various Army facilities. AMEDD
Patient Safety Representative LTC Robert
Durkee describes the benefits of the working
groups as numerous. Not only do the groups
bring together a wide range of talent and sub-
ject-matter expertise, they nurture policy
champions with deep investment and enthu-
siasm, and great credibility among staff. An
Guest Speaker Dr. Terry P. Clemmer, IHI Consultant, answers questions from members of
the Ventilator-Associated Pneumonia/Central Line Infections working group in September.
COL Carolyn Tiffany, Deputy Chief, MEDCOM Quality Management Division speaks to
the Ventilator-Associated Pneumonia/Central Line Infections working group.
unexpected, transformational by-product of
the working groups has been the dialogue
they have created between policy and practice.
The Army’s system-wide experience with its
Ventilator-Associated Pneumonia policy illus-
trates the synergies that come from such
hands-on policy development. Based on the
input the working group brought to policy
discussions, and supported by the enthusiasm
and creativity of staff implementation, Army
users identified oral care as an additional
component of preventing ventilator-associat-
ed pneumonias. AMEDD has added oral care
as a bundle component throughout its MTFs,
responding to IHI’s suggestion that all partic-
ipants in the 5 Million Lives Campaign add
their own changes in care to reduce mortality
and other forms of harm. In addition, as an
active participant in the Campaign, AMEDD
has shared its ideas and progress with IHI,
who uses such lesson learned to refine best
practices for all participants.
Brooke Army Medical Center —
Extraordinary Leadership
Yields Impressive Outcome
Work currently underway at Brooke Army
Medical Center (BAMC) highlights the suc-
cessful adoption of the IHI recommenda-
tions within one facility. The Infection
Control Team at BAMC, under the leader-
ship of Dr (MAJ) Chris Humphries, spear-
headed implementation of the Ventilator-
Associated Pneumonia bundle last year.
Thanks to the team's leadership and the
extraordinary cooperation among physi-
cians and nursing staff, BAMC has experi-
enced zero pneumonias associated with
ventilators in one of its ICUs. The team is
now meeting to formally adopt the IHI
Central Line bundle. This effort enjoys
strong Command support. It is eagerly
anticipated and is expected to decrease
infections among BAMC patients.
Tripler Army Medical Center —
Leader in Rapid Response System
The development of the Rapid Response
System at Tripler Army Medical Center
PATIENT SAFETY FALL 2007 3
5 MILLION LIVES
CAMPAIGN
Continued from Page 3
(TAMC) provides an example of the
impact the IHI interventions can create as
they spread outward from individual facili-
ties to the wider AMEDD system. Dr. Eric
Crawley, Chief of Critical Care at TAMC,
described the first TAMC RRT (deployed
in November, 2006) as a force for positive
change in the inpatient venues, leading to a
safer and more collaborative environment.
(See Patient Safety Newsletter, Spring
2006) Since then TAMC has developed a
pediatric RRT, and is deepening its RRT
expertise by examining the effects of the
RRT on ICU outcomes. Tripler staff will
co-facilitate the next Rapid Response Sys-
tem Working Group for AMEDD, sharing
their many years of successful RRT experi-
ence to the benefit of patients across the
Army system.
Navy Finds Both Challenge and
Affirmation in IHI Collaboration
By joining the IHI 5 Million Lives Cam-
paign, the Navy Command is affirming
efforts already underway at many of its
medical treatment facilities. The current
Navy policy directs the implementation of
four IHI bundles — Ventilator-Associated
Pnemonia and Central Line Infections for
facilities with intensive care units (ICUs);
Prevention of Adverse Drug Events and
Harm from High Alert Medications for
others. The policy also allows Commands
to select and report on additional bundles
with which they may already be engaged.
All bedded facilities within the Navy are
being registered with IHI. They will begin
sharing data as soon as the dedicated web-
sites are up and running. With implemen-
tation of this collaboration, facilities
across the system are receiving a strong
signal from the top that the Navy experi-
ences related to these interventions will
now become part of the national effort to
create benchmarks and measurements to
support best practices and lessons learned.
National Naval Medical Center, Bethesda
Based on its history with IHI, dating back
to the beginning of the 100,000 Lives Cam-
paign in 2005, the National Naval Medical
Center(NNMC), Bethesda can attest to the
benefits of engaging in this extended effort
to save 5 million lives. CDR James Dunne,
then Medical Director of the Intensive
4 FALL 2007 PATIENT SAFETY
Care Unit, and CDR Patrice Bibeau, then
Associate Director of Cardiovascular and
Critical Care, began a voluntary, limited
participation in the early IHI efforts to
prevent Central Line Infections and Venti-
lator-Associated Pneumonia. They formed
a multi-disciplinary core team to incorpo-
rate the recommended care components
into the critical care practice at Bethesda.
Even on a limited basis, they have found
their IHI collaboration a beneficial assist
in beginning their practices to include
improvements recommended by IHI such
as on-site debriefings and shared results
with ICU staff.
Barbara Cilento, Clinical Nurse Specialist
for the NNMC ICU reports that as the
Navy begins its full participation in the
IHI campaign, success in decreasing both
ventilator-associated pneumonias and cen-
tral line infections has been significant.
Going forward she envisions a unique con-
tribution to the IHI collaboration from
DoD providers at NNMC and other MTFs
— customizing IHI recommendations to
address the needs of the war-wounded, for
whom infection control potentially pres-
ents new challenges.
Naval Medical Center, San Diego
The official Navy policy to join IHI has
been well-received in other facilities.
CAPT John Parrish, Director of the Med-
ical Intensive Care Unit (ICU) at the Naval
Medical Center San Diego (NMCSD)
reports that most staff are aware of the IHI
5 Million Lives Campaign and are pleased
to become part of such a positive national
initiative. Rapid Response Teams (RRT),
Ventilator-Associated Pneumonia and
Central Line Infections have been the
focus of significant attention at NMCSD
over the last two years, well prior to the
current IHI policy. Internal data on the
efficacy of RRTs has been so compelling
that the use of the RRT has expanded
throughout the hospital.
CAPT Parrish believes that the official deci-
sion to join the 5 Million Lives Campaign,
with its data-sharing mandate, will elevate
existing efforts across the Military Health
System. The transparent reporting required
by IHI provides a national standard for best
practices and lessons learned. Being a part
of this national dialogue presents a chal-
lenge to continually measure and improve,
while providing affirmation and encourage-
ment for the on-going efforts of Navy
providers as they continue their focus on
high-impact interventions.
IHI Conference — December, 2007 —
Inspiration for Continued Success
The Institute for Healthcare Improvement
19th Annual Forum on Quality Improve-
ment in Health Care will be held Decem-
ber 9 through 12 in Orlando, Florida.
Representatives of the Department of
Defense Patient Safety Program will be in
attendance.
Aptly themed “The Energy of Many”, the
national forum draws nearly 6,000 health
care professionals from around the world.
A Patient Safety track is planned with
numerous workshops related to the inter-
ventions of the 5 Million Lives Campaign.
Sharing of lessons learned and dialogue
among the many attendees is meant to
energize the already impressive work of the
Campaign. DoD PSP attendees are proud
to bring Service successes to this world-
wide conversation.
As Army, Navy and Air Force participation
in the 5 Million Lives Campaign continues
and expands, the catch-phrases of the 2007
IHI Annual Forum offer inspiration and
encouragement. Drawing on the “Energy
of Many” theme, attendees are urged to
“Be A Spark”, and are reminded that “If
you have enough sparks, you can start a
fire”. The impressive work already accom-
plished by the DoD facilities clearly is but
the beginning of a firestorm of high-
impact patient safety initiatives across the
Military Health System.
 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting
PREVENTING
IN-PATIENT SUICIDE
Ensure a Safe Environment thru
Assessment, Observation, Education
Pamela Copeland, JD, RN, BSN
Patient Safety Manager
Approximately 10.8 per 100,000 deaths in
the United States result from suicide
(National Center for Health Statistics
2007). In 2007 the Joint Commission prom-
ulgated National Patient Safety Goal #15
requiring organizations to identify safety
risks inherent in patient populations after
finding that patient suicide was the most
frequently reported sentinel event between
1995 and 2005.
Environmental safety as defined in health-
care encompasses both the physical envi-
ronment and the way patients are cared for
by staff. Increasingly, patients at risk for
suicide are located in environments outside
the closed behavioral health unit. Approxi-
mately 1,500 suicides take place in inpa-
tient hospital units in the United States
each year (Busch 2003). While there are a
plethora of means by which patients
attempt or commit suicide (ingestions,
weapons), the majority occur from hanging
or jumping. Suicidal risk patients impose a
responsibility on the healthcare team to
provide the safest overall physical environ-
ment. Thoughtful patient care planning
and diligence in promoting a safe and
secure environment are the best strategies
for saving a life.
Assess the Environment
Conduct routine multidisciplinary pro-
active environmental safety rounds. Whether
the location is a behavioral health unit, ED,
ward or ICU, staff must stand in the shoes of
a suicidal patient and consider the many
items that may be used to commit suicide,
particularly:
Hanging risks — interior doors, privacy cur-
tain support structures, grab bars, plumbing
fixtures, sink drains and bed frames can be
used as attachment points. To address:
• shorten bathroom doors; modify their
hinges
• use curtains, accordion doors or pocket
doors and breakaway rods
• cover plumbing fixtures and grab bars
• lock bathrooms and non-supervised areas
if allowed
• eliminate drop ceilings and other means of
hanging: sheets, pants, belts, shoelaces,
pantyhose, bathrobe sash, towels, draw-
strings from clothing, cords
Smothering hazards — eliminate plastic show-
er curtains, trash liners, disposable gloves.
Eating utensils — replace with plastic cutlery,
paper plates, bowls and cups.
Glass — eliminate by laminating pictures, or
using safety glass or Plexiglas.
Jumping risks — minimize by ensuring that
windows are tempered, shatter resistant and
cannot open more than a few inches, and by
alarming doors leading to the roof.
Elopement risk — minimize by assigning the
patient to a room that is easy to observe and
access, away from exits. Admit the patient to
a more secure location as soon as practical, if
indicated.
Patient’s belongings — immediately sepa-
rate, search and sequester potentially harm-
ful items (weapons, medications, drugs, Example of how a door can be used as an
sharps objects). Remove belts, shoelaces, ties, attachment point for hanging. Photo reprinted
from May 2005 publication: Kenneth R. Yeager, Radu
pantyhose, drawstrings from clothing; Saveanu, Albert R. Roberts, Gabby Reissland, Dan Mertz,
sequester personal belongings and clothing Avni Cirpili, and Ron Makovich (2005). Measured Response
to Identified Suicide Risk and Violence: What You Need to
in an inaccessible area. If practical, have the Know About Psychiatric Patient Safety Brief Treatment and
patient wear a hospital gown. Crisis Intervention., May 2005; 5: 121 - 141.
Observation
At-risk patient suicide observation is a staff-
intensive intervention. Most commonly one-
to-one, observations may be constant, ran-
dom, every 15 minutes, or at known places.
Random observations are recommended to
dissuade patients from planning self-harm
around a known schedule.
The effectiveness of any observation is
enhanced when it is carefully performed
according to clear organizational policies
which define levels of observation, require
written orders documenting the need for
observation, and outline exactly what must
be observed and documented. Care plans Model showing how even a call button
should be altered to suit individual patients; cord can be used for hanging by an at-risk
nurses should be free to intensify observa- patient. Photo reprinted from May 2005 publication:
Kenneth R. Yeager, Radu Saveanu, Albert R. Roberts, Gabby
tion without seeking a physician’s order; and Reissland, Dan Mertz, Avni Cirpili, and Ron Makovich
observation orders should be reviewed and (2005). Measured Response to Identified Suicide Risk and
Violence: What You Need to Know About Psychiatric
renewed or modified as appropriate. Patient Safety Brief Treatment and Crisis Intervention., May
Article continued on page 8 2005; 5:121-141.
PATIENT SAFETY FALL 2007 5
 PATIENT SAFETY IN ACTION
Experiences and Suggestions From the Field
ARMY DENTAL
COMMAND
TAKES LEAD ON
PATIENT SAFETY
Innovative Display Booth
Introduced at AMSUS Conference

The US Army Dental Command received

national recognition when it displayed the
first-ever dental patient safety promotion
booth at the AMSUS (The Association of
Military Surgeons of the U.S.) Conference
November 12-15. Staffed by Ms. Roberta
Sjelin, MEDCOM Patient Safety Coordina-
tor, the booth is being used to promote new
Army Dental patient safety initiatives, using
the theme: “A Full Time Commitment, Not A
Part Time Practice.”
Hardly a stranger to patient safety, the Army
Dental Command has sponsored patient
safety initiatives since 2004. While dental
safety is not included under Joint Commis-
sion oversight unless patients are hospital-
ized, it is mandated under the Department of
Defense Patient Safety Program guidelines.
The Army has developed a dental safety pro-
gram which mirrors the larger military med-
ical model. Dental officers at various facili-
Dental Patient Safety Booth with Dental Command staff, from left to right: MAJ Tim
Fildes (British Exchange Officer), SGM Richard Orona, COL Ann Sue von Gonten, Rober-
ta Sjelin, Dental Patient Safety Consultant, and SFC Katherine Carrasco.
ties assume safety managerial responsibilities forcing patients’ involvement in their own
in addition to their regular duties. They col- health care. The five steps outlined in the
lect data on safety-related dental events and brochure encourage patients to be active in
report them monthly to a central repository. their dental care, to share medical history
with their dentists, to discuss treatment
With a history of strong support from Army choices, to understand treatment proce-
Dental Command Headquarters, the dental dures, and to complete home care and fol-
safety program has been an active partner in low-up plans. Currently, the dental program
military patient safety efforts. It has pro- is developing guidelines for their own “time
duced a patient-centered brochure entitled out” policy, focusing on correct identifica-
Five Steps to Safer Dental Care aimed at rein- tion of dental patients and procedures.

Five Steps to Safer Dental Care brochure, part of the Army Dental Command patient safety initiative.

6 FALL 2007 PATIENT SAFETY

 PATIENT SAFETY IN ACTION
Experiences and Suggestions From the Field
MICROSYSTEMS
SUCCESSES
Pilot Centers Share
Experiences of First Year

The spring 2007 Patient Safety Program

Newsletter reported on the Center for Educa-
tion and Research in Patient Safety (CERPS)
pilot project to introduce the Microsystems
conceptual framework to the Military Health
System (MHS). In late 2006, staff at the Naval
Hospital Sigonella and Vincenza Army
Health Clinic completed prework, hosted
three day training sessions with CERPS
instructors, and launched initial improve-
ment actions. The sites have continued to
work with CERPS in supervised follow-up. A Dr. Luan leading the Microsystems team at Vincenza Army Health Clinic through their
first year progress review recently completed training session.
by Dr. Diana M. Luan, PhD, RN, MPA, MS,
CERPS Senior Research Policy Specialist
revealed process improvements and a num-
ber of unexpected positive outcomes as well.

“Microsystems took down any

internally perceived barriers, leading
us more towards ‘how can we do
this?’ and away from ‘I don’t think
we can do this.’” Team Member

Over the last year, Dr. Luan has stayed in close

contact with each pilot site, providing guidance
in monthly telephone calls. Staff have filed
activity reports each month with CERPS, and
have briefed their Commanders on a monthly
basis. Dr. Luan believes that Command
involvement, formalized monthly reporting
and frequent documentation have been among
the critical elements in the Microsystems-
based changes. Success has also been enhanced
by team stability, with each team member hav-
ing at least one year of longevity. Perhaps the
most fundamental element of Microsystems
success in these facilities has been the strong
engagement of the teams. An important lesson
learned from the pilot experience is that the
team must choose a first improvement action
that truly matters to them.
Staff at Naval Hospital Sigonella outline a process they have targeted for Microsystem
assessment, diagnosis, treatment and follow-up.
Unexpected outcomes reported by the facili-
ties suggest that Microsystems-focused
change carries the potential to generate self-
perpetuating improvements. Within the
team itself, participants reported a sharper
focus on the positive, leading to concentra-
tion on solutions rather than barriers. The
pilot sites also found their physicians were
quite engaged in the process, and other
departments voluntarily asked to participate
in the improvements and process. A Facility
Commander summed up the experience in
these words: “If we make these techniques
into habits, we will naturally spread the word
on and on throughout the system.”
Currently, these sites continue to engage in
the Microsystems change process. CERPS has
begun working with other facilities. If you are
interested in learning more about Microsys-
tems and its potential to impact in your MTF,
contact Diana Luan: dluan@usuhs.mil.

PATIENT SAFETY FALL 2007 7

PREVENTING
IN-PATIENT SUICIDE
Continued from Page 5
Safe Transfer
Transferring patients at risk for suicide
within the facility or to another facility
requires a well-coordinated and clearly
defined patient handoff. The ECRI Insti-
tute recommends a higher level of obser-
vation during transfer; communicating
the patient’s suicide risk to transporting
and receiving staff; reinforcing to them
their responsibility to keep the patient safe
and the means they may use to address
and/or de-escalate a crisis. Off campus
transfers are safest via ambulance, with
one-to-one attendance. If another vehicle
is used, assess it for items that may cause
self-harm; use added safety precautions,
such as safety locks; and increase atten-
dance to two-to-one.
Education
Environmental safety encompasses staff
response to self-harm events. Prompt
responses and efficient interventions may
reduce the lethality of the suicide attempt.
Suggestions for improving staff response
include drills using mock scenarios and
YOU OUGHT TO
BE IN PICTURES!
Send Your Photos to the
Patient Safety Photo Album
If one picture is indeed worth a thousand
words, then we want YOUR picture to
help us tell the story of patient safety ded-
ication and success in our Army, Air Force
and Navy facilities. The Patient Safety
Newsletter is planning a new feature,
beginning in 2008 — the Patient Safety
Photo Album. In each issue of the
Newsletter going forward anywhere from
one to four photos of patient safety-relat-
ed images will be published.
The Photo Album is intended to be a pic-
torial representation of the faces of
8 FALL 2007 PATIENT SAFETY
reviewing actual suicide events as a teach-
ing tool. Reinforce best practices for rescu-
ing and recovering an individual.
Patient and family education, a vital com-
ponent of the team approach to promoting
a safe environment, must be implemented
at the beginning of the patient encounter
and continuously reinforced through dis-
charge. At risk patients must be assured
that personal and environmental depriva-
tions are a non-punitive component of
their evolving care plan. Since family mem-
bers and visitors may unknowingly intro-
duce potentially lethal items to the at-risk
patient, staff must be alert to all visitor
encounters, using them as an opportunity
to both educate and protect.
For more information on ensuring a safe envi-
ronment and for reference material, contact
author at: Pamela.Copeland@afip.osd.mil
patient safety among our DoD facilities.
The photos will not be part of any article;
they will be stand-along images of the
many and varied patient safety efforts
that take place across the DoD Military
Health System every day. From every Ser-
vice, we are interested in getting to know
the people who work so hard to make
patient safety happen — doctors, nurses,
respiratory therapists, housekeepers,
patient safety managers. Whatever the
discipline or occupation, we’d like to
share your efforts in an on-going photo-
graphic feature.
In order to obtain photos for publication
in the Photo Album, we need your help.
Please take photos of patient safety-relat-
ed activities in your facility and send
them on to the Newsletter. (A high resolu-
tion jpg image works best). Photos can
PATIENT SAFETY
PROGRAM NEWSLETTER
Published quarterly by the Department of Defense
(DoD) Patient Safety Center to highlight the progress
of the DoD Patient Safety Program.
DoD Patient Safety Program
Office of the Assistant Secretary
of Defense (Health Affairs)
TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike
Falls Church, Virginia 22041
703-681-0064
Forward comments and suggestions to:
DoD Patient Safety Center
Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100
Silver Spring, Maryland 20910
Phone: 301-295-7242
Toll free: 1-800-863-3263
DSN: 295-7242 • Fax: 301-295-7217
E-Mail: patientsafety@afip.osd.mil
Website: http://dodpatientsafety.usuhs.mil
E-Mail to editor: poetgen@aol.com
DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM
COL Steve Grimes
DIRECTOR, PATIENT SAFETY CENTER
Geoffrey Rake, MD
DIRECTOR, CENTER FOR EDUCATION
AND RESEARCH IN PATIENT SAFETY
Eric S. Marks, MD
DIRECTOR, HEALTHCARE TEAM
COORDINATION PROGRAM
Ms. Heidi King
SERVICE REPRESENTATIVES
ARMY
LTC Robert Durkee
NAVY
Ms. Carmen Birk
AIR FORCE
Lt Col Kathryn Robinson
PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
Phyllis M. Oetgen, JD, MSW
show personnel at work with patients,
training, or posed. Images of patient safe-
ty tools, reminders and printed materials
are also welcome. There is no limit to the
number of photos each facility can send,
and no time limit for submission. The
Photo Album will be a regular feature of
the newsletter beginning with the Winter
2008 issue. You should accompany each
image with a caption identifying the facil-
ity, the personnel pictured and the con-
text of the picture.
Please send photographs to the Newsletter,
attention Editor, at poetgen@aol.com. Your
photo will be acknowledged, and you will
be notified when publication is planned.