SPECIAL TRICARE CONFERENCE EDITION

JANUARY / FEBRUARY 2006 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

2005 PATIENT SAFETY AWARDS

A
highlight of the State of the Military Health System (MHS) - 2006 Annual TRICARE Conference is the pres-
entation of the Patient Safety Awards. This formal recognition of excellence and innovation in patient safe-
ty is especially consistent with the theme of this year’s Conference: Military Medicine: Transforming the
Future. As 2006 begins, the Conference is an important opportunity to explore the current and upcoming achieve-
ments of the MHS, and to share knowledge, expertise and best practices. The Patient Safety Program is an integral
part of the extraordinary care that is military medicine. The 2005 Patient Safety Awards reflect the energy, creativ-
ity and expertise of the Safety Program, and stand as achievements to be recognized and contributions to be shared
across the MHS and beyond.

Created in 2003, the Patient Safety Awards recognize leadership and innovation in quality, safety and commit-
ment to patient care by the Military Treatment Facilities. They are meant to reward successful patient safety efforts,
particularly in the development of a culture of safety; to inspire increased patient safety efforts; and to communi-
cate successful strategies throughout the MHS. The Awards are presented in three categories: Technology, Policy
and Procedure, and Team Training. Successful initiatives are data driven, practical, creative and transferable across
the MHS. They have been tested and proven to reduce errors and improve patient safety and outcomes.

R
ecipients of the 2005 Patient Safety
Awards are:
Policy and Procedure: 59th Medical
Wing, Wilford Hall Medical Center, Lack-
land Air Force Base
Team Training: 89th Medical Group,
Malcolm Grow Medical Center, Andrews
Air Force Base
Technology: National Naval Medical
Center, Bethesda
Policy and Procedure Award
59th Medical Wing
Wilford Hall Medical Center
Title: Rapid Identification & Registration
Process for the Trauma Patient
The 59th Medical Wing at Wilford Hall
reviewed and optimized its existing regis-
tration and identification process for trau-
ma patients. The new process, described as
a “mistake-proof solution” by the Hospital
commander, accurately identifies trauma
patients who cannot identify themselves at
registration using two Joint Commission
on Accreditation of Healthcare Organiza-
tions (JCAHO) required unique patient
identifiers, which continue to be used for
all points of service throughout the
patient’s hospitalization.
Impetus for the initiative came from
patient safety event reporting. The proac-
tive process in use to rapidly register trau-
ma patients to the hospital, while expedit-
ing the typing and cross matching of donor
blood requests, was reported to sometimes
cause unacceptable delays or interruptions
in the release of blood from Blood Bank
Services due to conflicting patient names
and identification numbers.
The optimized policy, designed to
decrease misidentification events and treat-
ment delays, uses two unique patient iden-
tifiers – a registration number and a patient
name. The Emergency Department creates
a registration identification band and
places the band on the patient’s ankle (to
avoid the likelihood of removal). The band
remains on the patient until discharge; it is
used to verify the patient against all pre-
admission orders. Upon formal admission
to the hospital, the patient is given an
admission bracelet, which includes his or
her legal name and the existing registration
number, already on the ankle band. This
unique identifying number, which is
repeated on both bands and is used at all
points of service through discharge, has
eliminated confusion, miscommunication,
and delays and interruptions in treatment.
To maximize the effectiveness of this
process, the information originally used,
including the unique identification num-
ber, the name assigned at admission, and
other identifying information, must not be
changed during admission. Corrective
changes are done only after discharge.
Team Training Award
89th Medical Group
Malcolm Grow Medical Center
Title: Preoperative Operational Risk
Management “Checkride”
Effective teamwork has long been rec-
ognized as critical to aviation safety. As the
elements of patient safety have come to the
forefront of medical practice, comparisons
abound between the aviation system and
Continued on Back
Patient Safety
Awards
Continued from Front
the patient care system. Teamwork training,
especially in the high-risk environments of
the emergency room, labor and delivery suite
and operating room, is an expanding sub-set
of patient safety best practice.
In a unique effort to enhance teamwork,
the 89th Medical Group has adapted the pre-
flight safety assessment long used by flying col-
leagues on the tarmac to the operating rooms
at Andrews AFB. A multi-disciplinary team
representing operating room (OR) stakehold-
ers began meeting in November 2004 to devel-
op the Surgical ORM check-list, a tool
designed to mimic the pre-flight checklist.
Now nearly a year old, the checklist is
completed by the OR nurse in collaboration
with other team members (surgeon, techni-
cian and anesthesia provider) during a “team
huddle” prior to the start of each surgical
case. The staff self-assesses their procedure
performance frequency and rest status on a
scale of 1 to 5, and rates external risk factors
such as case type, frequency performed at
the facility, complexity of case and American
Society of Anesthesiologist’s (ASA) classifi-
cation of physical status. A total risk factor
score of low, moderate or high is determined
for each case. Depending on the risk assess-
ment and team discussion, the case proceeds,
is cancelled or is modified in some way to
address a perceived problem.
The checklist was conceived as a way to
PATIENT SAFETY PROGRAM SALUTES ALL PARTICIPANTS
The Patient Safety Program wishes to recognize and thank all the MTF’s submitting projects for Award consideration this year. The ini-
tiatives reflect the energy and commitment to patient safety that our providers bring to patient care each and every day.
Policy and Procedure
“Care of Surgical Instrumentation”
10th Medical Operations Squadron,
10th Medical Group, USAF Academy
“Good Catch Program”
US Army Dental Activity, Fort Bragg
“Good Catch: Netting Benefits”
US Naval Hospital, Yokosuka, Japan
“An Evidence-Based Approach to the Devel-
opment of a Falls Prevention Program”
National Naval Medical Center, Bethesda
“Process Improvement, Pap Specimens”
improve care delivery performance, estab-
lish/reestablish situational awareness and
assign/reassign responsibilities and tasks
depending on experience and competency
levels. Assessment forms are collected and
analyzed for trends. To date, although no
trends have been revealed, the checklist has
been instrumental in identifying issues need-
ing early intervention, thus preventing possi-
ble cancellations and/or risks to patients’
safety.
Technology Award
National Naval Medical Center
Title: Composite Healthcare System
Technology Utilized for the JCAHO
National Patient Safety Goal
Reconciliation of Medications
The National Naval Medical Center
(NNMC), using the Composite Healthcare
System (CHCS) already operational
throughout the MHS, developed a medica-
tion reconciliation process to meet the
requirements of the Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO) 2006 Patient Safety Goal #8, which
directs health care organizations to “accu-
rately and completely reconcile medications
across the continuum of care”.
The multi-disciplinary team from
NNMC tasked with addressing the JCAHO
mandate recognized that, while the JCAHO
goal may be new, the technology necessary to
meet the requirements of effective medica-
tion reconciliation already exists in CHCS.
6th Medical Group, MacDill AFB
“Read Back of all Respiratory Therapy
Critical Test Results”
60th Medical Group, Travis AFB
“Teaching Patients to Become Savvy
Consumers of Heath Care”
59th Medical Wing, Lackland AFB
Team Training
“Making a Difference Through Teamwork”
366th Medical Group, Mountain Home AFB
“Team Training for Improved Team Perfor-
mance that Promotes Patient Safety”
This common source for medication infor-
mation in the MHS captures outpatient and
inpatient drugs provided through Depart-
ment of Defense (DoD) pharmacies. Access-
ing the current list of medications already
recorded within CHCS for a given patient
provides a base-line list of medications, and
is a logical first step in the medication recon-
ciliation process.
The CHCS system at NNMC was adapt-
ed to allow a provider, once logged into
CHCS, to access a Medication Reconciliation
Menu with options. The team developed
specialized medication reconciliation forms
to compare a patient’s profile of current
medications against medication orders writ-
ten at admission, transfer and discharge. The
printed profiles, when provided to patients,
engage patients in the medication reconcilia-
tion process (per JCAHO mandate). Utiliz-
ing the comparison process provided by
these forms, inconsistencies in medication
orders are easily recognized and addressed.
CHCS print options allow providers to
continue or discontinue medications already in
the CHCS system without re-writing orders.
Only new orders must be written, which
reduces the potential for medication errors and
increases provider productivity during patient
transitions in admission, unit transfers and dis-
charge. By adapting an existing common tech-
nology, NNMC has provided a safe and effi-
cient way to reconcile medications, engage
patients in the process, save provider time and
resources, and reduce medication errors across
the spectrum of the MHS.
374th Medical Group, Yokota AFB, Japan
“Integrated Safety Training Program”
433rd Aeromedical Evacuation Squadron,
Lackland AFB
Technology
“2005 National Patient Safety Goal Calendar”
55th Medical Group, Offutt AFB
“The Use of Bar Coding to Improve
the Accuracy of Patient Identification”
3rd Medical Group, Elmendorf AFB
“Fall Reduction on Lobby Stairs”
14th Medical Group, Columbus AFB