THIS ISSUE TOOLS TO ASSIST IMPLEMENTATION OF NEW JCAHO GOALS

P AFETY
ATIENT
FALL 2005

Page 3 PSC – Safer Handoff Tips

Page 4 PSC – Retained Surgical Instruments

FALL 2005
S Page 6 Patient Safety Awards Reminder

Page 7 Patient Safety In Jeopardy?

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

PATIENT SAFETY PROGRAM TOOLS

Guidance in Meeting JCAHO 2006
Patient Safety Goals

T
he Joint Commission on the Accred-
itation of Healthcare Organizations
(JCAHO) reviews and enhances its
set of National Patient Safety Goals annual-
ly. First published in 2003, the goals are pri-
marily based on information derived from
the JCAHO Sentinel Event database. Their
purpose is to promote specific improve-
ments in patient safety by highlighting
problematic areas in health care, describing
evidence and expert-based solutions to
these problems, and evaluating accredited
organizations for continuous compliance
with the specific requirements associated
with each Goal.
The DoD Patient Safety Program is
committed to assisting providers as they
adapt their practices to implement the
requirements of the Patient Safety Goals.
The Toolkit and practice suggestions Sample slide from Handoff Toolkit Power Point presentation, illustrating the
information foundation for the “I PASS THE BATON” mnemonic.
described in this article have been devel-
oped specifically to provide DoD facilities
with background information and practi- HEALTHCARE COMMUNICATIONS training, and, in fact, the handoff is a famil-
cal guidance related to JCAHO Safety DURING TRANSITIONS OF CARE iar tool, utilized to improve communication
Goals 2E and 8A/B. In January 2006, and teamwork behavior. New JCAHO
accredited organizations must comply with The DoD Patient Safety Program (PSP) requirement 2E, which mandates a stan-
new implementation expectations for these has provided robust training in healthcare dardized approach to handoff communica-
goals. The Handoff Toolkit will be accessi- team coordination from its earliest days. As tions, shines a spotlight on this teamwork
ble on the DoD Patient Safety Website the PSP has matured, so has its team train- element, creating the opportunity to inte-
(https://patientsafety.satx.disa.mil) on ing curriculum, now known as TEAM- grate this existing team strategy across the
December 1st, and is recommended as a STEPPS, administered by the DoD Health spectrum of healthcare practice.
helpful template for Military Treatment Care Team Coordination Program. Strate- In elevating the handoff to the level of a
Facilities as they review their individual gies for effective handoff communications National Patient Safety Goal requirement,
procedures for handoff communications. have been an integral part of TEAMSTEPPS Continued on Page 2
Patient Safety
Program Tools
Continued from Page 1
JCAHO explains that “…the primary objec-
tive of a “hand off ” is to provide accurate
information about a patient’s/client’s/resi-
dent’s care, treatment and services, current
condition and any recent or anticipated
changes. The information communicated
during a hand off must be accurate...”
JCAHO’s implementation expectations for
effective handoff communications are that
handoffs be interactive communications that
include up-to-date information, and require
a process for verification of the received
information. Interruptions during handoffs
are to be limited, and the receiver of the
handoff information should have an oppor-
tunity to review relevant patient/client/resi-
dent historical data.
The Toolkit developed by the PSP Health
Care Team Coordination Program builds on
the knowledge base underlying existing team
training and TEAMSTEPPS in particular. It Sample slide from Handoff Toolkit Power Point presentation suggesting the NEXT STEPS
for MTFs in implementing Handoff initiatives.
begins with the JCAHO requirements, but
seeks to provide a fuller understanding of the prompts providers to share information within DoD facilities. As an acknowledged
components of effective information trans- more efficiently and effectively among all lev- leader in the field of teamwork training, the
fer. Users will find a thorough review of gen- els of professional expertise, making explicit DoD Health Care Team Coordination Pro-
eral industry and specific healthcare research the communication of information that has gram, with your help, is in a unique position
in the area. Lessons learned from experience often been lost during handoffs. to make a real contribution to our patients
in emergency departments, intensive care The Toolkit concludes with a set of rec- and providers alike by integrating teamwork
units and operating rooms are noted. A con- ommendations for each facility to consider as and communication and creating a model
sistent dilemma described in all settings is the it establishes its individual handoff program. handoff process.
challenge of balancing the need for efficiency From leadership support to program design
with the need for effectiveness in handoff to preferred tools, the recommendations MEDICATION RECONCILIATION PRACTICE
communications. Passing too little informa- cover the critical elements of the optimal SUGGESTIONS
tion increases the potential for errors; requir- healthcare handoff. Rather than prescribe one
ing too much information creates a burden- standardized approach, the Toolkit provides a The Center for Education and Research in
some process that may be ignored in the press full range of information designed to explain Patient Safety (CERPS) at USUHS has assist-
of day-to-day practice. and facilitate well-structured handoffs, which ed in developing a compendium of informa-
One goal of the Toolkit is to assist can be adapted to the diverse cultures of the tion, research and practice guidelines to assist
providers find a balanced process for hand- DoD medical community. Included in the MTFs develop a systematic process for recon-
offs across the continuum of care. To that Toolkit for use by facilities are an extensive ciling medications. This effort is a direct
end, five current strategies are discussed: the bibliography and list of relevant resources, response to JCAHO National Patient Safety
I-SBAR, Expanded I-SBAR, FIVE-Ps, Data helpful illustrations, Frequently Asked Ques- Goal 8, which requires that health care organ-
TRIANGLE and the I PASS THE BATON tions related to handoffs and TEAMSTEPPS, izations “accurately and completely reconcile
mnemonic. Each option is analyzed in the and a supporting Power Point presentation. medications across the continuum of care”,
context of human factors knowledge, medical Dr. John S. Webster, a member of the effective January 1, 2006. It builds on the
errors commonly seen during healthcare DoD Health Care Team Coordination Pro- proactive initiative introduced at the National
transitions, the complexities of the healthcare gram, believes this coordinated effort to Naval Medical Center (NNMC) Bethesda,
process, JCAHO mandates and the need to structure handoff communications provides where staff developed a workable, repeatable
balance effectiveness with efficiency. The I an opportunity for significant improvement management response to medication recon-
PASS THE BATON mnemonic, which stands in patient safety. Each Service will oversee ciliation using the existing capabilities of the
for Introduction, Patient, Assessment, Situa- implementation of the handoff initiatives Composite Health Care System (CHCS).
tion, Safety Concerns, Background, Actions, within its facilities. Feedback from healthcare In establishing medication reconciliation
Timing, Ownership and Next Steps, is recom- providers will be solicited and incorporated as a safety goal, JCAHO recognizes evidence
mended as the most intuitive, flexible strate- into the Toolkit, which will be reviewed and from numerous studies which documents a
gy in current use. I PASS THE BATON adjusted to reflect emerging best practices Continued on Page 8

2 FALL 2005 PATIENT SAFETY

 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting
Practicing Safe
Handoffs
Suggestions to Improve Problem Areas
Mary Ann Davis, RN, BSN, MSA
Nurse Risk Manager, Patient Safety Center
R
ecognizing the importance of the new
JCAHO 2006 Patient Safety Goal # 2E,
which requires the implementation of
a standardized approach to handoff commu-
nication, the DoD Patient Safety Center has
reviewed relevant literature and information
received from our Military Treatment Cen-
ters (MTFs). While the definition of a hand-
off — the transfer of information between
health care providers — seems easy to
understand, experience shows that achieving
an effective and efficient transfer continues
to challenge busy caregivers.
As you exchange information about your
patients, keep in mind that the primary
objective of a handoff is to provide accurate
information about a patient’s /client’s /resi-
dent’s care, treatment, services, current con-
dition and any recent or anticipated change.
JCAHO’s implementation expectations
require up to date information, interactive
communication, limited interruptions dur-
ing handoffs, a process for verification of the
received information and the opportunity by
the receiver of the handoff information to
review patient /client/resident historical
data.1
In DoD practice, as is true across the
larger healthcare system, handoffs are com-
mon in the emergency room and clinic set-
ting when multiple providers treat the
patient, during change of shift or personnel
and when a specialist or consultant is need-
ed. Providers rarely have complete medical
record information when the patient
receives care in multiple settings. Often,
patients are sent to facilities where the pre-
vious medical records are not available. In
the acute care setting the exchange of infor-
mation frequently occurs at change of shift
or change of coverage, commonly with
reports which are mostly verbal, and may be
ambiguous. Some handovers are done from
memory with no documentation.2 Impor-
tant information often is not conveyed
because it has not been included in the
record, it has been misinterpreted, or the
receiver is not in a position to effectively
hear and retain it.
As MTFs work to meet the JCAHO
expectations, aided by the DoD Toolkit out-
lined on page 1, the PSC offers these addi-
tional practical suggestions to assist in
improving the effectiveness of handoff com-
munications.
Clinical test orders and results
Commonly part of the information
handed off, orders and/or results may not be
known or documented at the time of the
handoff. Consider these improvements:

Include a laboratory flow sheet in the
medical record to document the tests
ordered, with order dates, test results, and
dates results are received.

Have technicians review the laborato-
ry flow sheet when preparing the record for
a patient’s appointment; print any labs/test
results that are not recorded; give test results
to the provider to review and record during
the patient’s appointment.

Have providers review the lab flow
sheet at each visit and retrieve, record or
order outstanding labs/test results.

Document verification of verbal com-
munication of laboratory results in the med-
ical record at the time the information is
communicated.

Have health care providers identify a
surrogate to review test results in their
absence.

Hand-carry reports of incomplete and
abnormal tests to the provider or surrogate;
enter results of incomplete or abnormal tests
into a database and review each month. Ver-
ify provider contact with the patient con-
cerning abnormal results.

Involve patients in their care. Ensure
that they understand what tests are ordered
and when they should receive results, thus
adding additional checkpoints to the test fol-
low-up process.3
Consultations between providers
The exchange of information among
consulting providers can be either verbal or
written, but special care must be taken to
ensure that it is complete, accurate and up to
date. These actions will improve this process:

Provider requesting a consult provides
the record and all appropriate information
(lab, radiographic, other diagnostic results)
for the consultant at the time of the exam.

Consult physician signs and date-
stamps the chart to indicate concurrence,
and initials the diagnostic result to indicate
that a review was performed.

Impromptu or “sidewalk” consulta-
tions can be particularly problematic. Have
the patient record and any diagnostic exams
present during all consults, rather than rely-
ing on a verbal description. Consult physi-
cian should initial diagnostic reports and
write a brief initial note, followed by a longer
report.

Provider-provider communication
should explicitly establish who has primary
responsibility and agree on a clear line of
responsibility for follow-up to prevent mis-
understanding.3
Documentation
Documentation should be reviewed
prior to, or at time of, handoff:

Medical staff should clarify critical
information (e.g. patient situation, safety
concerns, background, planned actions and
their timing, and those responsible for
patient care) in the medical record or the
appropriate transfer document. “I PASS THE
BATON”, a mnemonic recommended in the
Toolkit, will assist this process.

Log books or spreadsheets should be
managed by centralized personnel within a
clinic or ward to track tests and their results. 4

Utilize a white board or computer for
the most recent vital sign and test results
during shift reports. Update all patient infor-
mation prior to the report and highlight any
areas of concern that should be addressed.
1
Joint Commission 2006 National Patient
Safety Goals Implementation Expectations,
accessed 9/22/05, http://www.jcaho.org/ac
credited+organizations/patient+safety/06_nps
g_ie.pdf
23
Shepard, A; Kostopoulou, O. Fragmenta-
tion in Care and Potential for Human Error,
accessed 9/22/05, http://www.dcs.gla.ac.uk/~
johnson/papers/HECS_99/Sheppard_Kostopou
lou.htm
4
Gandhi, T. K. Commentary: Fumbled
Handoff: One Dropped Ball after Another, ANN
Intern Med. 2005; 142:352-358
PATIENT SAFETY FALL 2005 3

The Final Count
Retained Surgical Foreign Bodies
Pamela Copeland, RN, BSN, JD, ARM
Nurse Risk Manager, Patient Safety Center
F
ailure to remove surgical instruments at
the end of a surgical procedure may be
a more common occurrence than sus-
pected. A recent study reports that this may
occur in as many as 1 out of every 100 cases
to as few as 1 out of every 5000 surgical cases,
with associated mortality ranging from 11 to
35%.1
The process by which counts are per-
formed is not standardized. Individual hospi-
tal policies vary widely, relative to their surgi-
cal sponge/sharps/instrument counting pro-
cedures. The Joint Commission on the
Accreditation of Hospitals (JCAHO) does
not dictate that counts must be conducted
nor does it prescribe how counts should be
conducted in the facilities that perform them.
Historically, the JCAHO sentinel event policy
has specifically stated that “unintentionally
retained foreign body without major perma-
nent loss of function” does not require
reporting.2 In June 2005, JCAHO revised the
list of reviewable sentinel events to include
the unintended retention of a foreign object
in an individual after surgery or other proce-
dure.3
According to Gibbs et al., the prevalence
and severity of this target problem is
unknown, and without accurate information,
the true magnitude of the opportunity for
impact is unclear.4
The Kaiser, et al, study reviewed 67 med-
ical malpractice claims involving retained
foreign bodies.5 The study notes:
1. 55% of retained sponges were found
after abdominal surgery, 16% after vaginal
surgery. Falsely correct sponge counts can be
attributed to:

Team fatigue

Difficult operations

Sponges “sticking together”

Poor counting system
2. In cases involving retained sponges, the
sponge count had been falsely reported in
76% of non-vaginal surgeries; in 10% of the
cases no sponge count had been conducted.
Incorrect sponge counts that were accepted
prior to closure resulted from:

Surgeon dismissing an incorrect count
without re-exploring the wound.

Nursing staff allowing an incorrect
count to be accepted.

In 3 of 29 cases in which inter-opera-
4 FALL 2005 PATIENT SAFETY
tive x-rays were used to detect radiopaque
sponges, the radiograph was falsely negative.
The authors note that the literature
describing the incidence of iatrogenic foreign
bodies is highly limited in quantity and qual-
ity. Additionally, the existing system of
sponge and instrument counts probably
works well, but there is no evidence to
describe the actual failure rate. What little
evidence exists suggests that system failures
are the result of human related factors (i.e.,
the count is not performed, or is ignored),
and that ancillary methods such as x-rays are
also fallible. The authors conclude that the
industry is left with a paucity of data regard-
ing the prevalence of this error and the effec-
tiveness of preventative measures.6
A recent study by Gawande, et al, consid-
ered the risk factors for retained instruments
and sponges after surgery.7 They conclude
that “studies of error to date have generally
measured only the frequency of the outcomes
of specific types of errors, not the roles of
particular contributing factors.”8 Their
research team used a retrospective case-con-
trol design involving the records of medical
malpractice claims and incidence reports.
Additionally, members of operative teams
were interviewed. In this study, 54 cases
involving 61 events were reviewed (69%
sponges and 31% instruments).9
According to Gawande, et al, cases involv-
ing the retention of a foreign body after sur-
gery significantly increased in emergencies,
unplanned changes in procedures, and with
individuals having a higher body-mass
index.10 The group’s findings support the
confirmation that leaving behind foreign
bodies in a patient after surgery is an uncom-
mon but dangerous error. They note the fol-
lowing sequelae:

In one case, the retained object result-
ed in death.

In 22% of the cases, the retained for-
eign bodies resulted in small-bowel fistulae,
obstruction, or visceral perforations.

69% of the patients required re-opera-
tion for removal of the object and manage-
ment of the complication.

The foreign body in the remaining
patients
- was expelled,
- could be removed at the bedside,
- was discovered incidentally and
removed at the time of another operation.
The majority of surgeons and nurses typ-
ically rely on the practice of counting the
sponges, sharps, and instruments as a means
of eliminating the possibility of retained for-
eign bodies. There are reports that some
medical facilities have abandoned this prac-
tice.11 Use of this simple, preventive, and
widely accepted measure is not universal.
"Legislation does not prescribe how counts
should be performed, who should perform
them, or that they need to be performed.12
The law only requires that foreign bodies not
be negligently left in patients.”13 The Associ-
ation of Operating Room Nurses (AORN)
has published accounting guidelines for
instruments used during surgical proce-
dures. The following practices were devel-
oped by the AORN Recommended Practices
Committee and became effective January 1,
2000.
“Sponges should be counted on all proce-
dures in which the possibility exists that a
sponge can be retained. Sponge counts
should be taken:
1. Before the procedure to establish a base-
line.
2. Before closure of a cavity.
3. Before wound closure begins.
4. At skin closure or end of the procedure.
5. At the time of permanent relief of either
the scrub person or the circulatory
nurse.”14
The purpose of these prudent patient
safety measures is to ensure that discrepan-
cies at any stage of the surgery will require the
team to do a repeat count. If the discrepancy
persists, then appropriate steps will be taken
to locate any unaccounted items.
Retained sponges and instruments con-
tinue to be a disturbingly repetitive problem.
Verna Gibbs, MD, of the University of Cali-
fornia at San Francisco notes a continuing
mantra that “current preventative practices
fail due to human related factors. Surgeons
use nonradiographically detectable sponges,
counts are not performed, and when they are
performed and errors occur, backup detec-
tion systems are not systematically
employed.”15
JCAHO now requires this event to be
reported regardless of the patient outcome.
Collection of this data will assist the industry
accurately quantify the prevalence of this
event type. Through qualitative analysis of
the data and methodical human factor
assessment, guidelines and tools can be
developed for surgical teams and their facili-
ties to implement. This process change will
enable the team to no longer ask the question
“was the count correct” but to ask and accu-
rately determine “is there a sponge or instru-
ment in the patient?” before finally closing
the surgical site.
 1
Laurwers PR, n Hee RH. Intraperitoneal
gossypibromas: the need to count sponges.
World J Surg 2000;521-527.
2
Wig JD, Goenka MK, Suri S, Sudhaker PJ,
Vaiphei K. Retained surgical sponge: an unusu-
al of intestinal obstruction. J Clin Gastroenterol
1997;24:57-58.
3 9
Sentinel Event -http://www.jcaho.org/ac
credited+organizations/sentinel+event/se_inde
x.htm Accessed October 17, 2005.
4 16
Gibbs VC, VaAuerbach AD. Chapter 22.
The retained surgical sponge www.ahrq.gov/
clinic/ptsafety/chap22.htm - 10k. Accessed
October 17, 2005.
5 17
Kaiser CW, Friedman S, Spurling KP, Slow-
ick T, Kaiser HA. The retained surgical sponge.
Risk Reduction Strategies for Retained Foreign Bodies*
Surgeons
Confirm counts when passing off needles and sponges.
Never cut sponges. Each sponge used should have an x-ray
detectable strip.
Do not prop up internal organs with surgical towels.
Ensure counts are done on all items.
Inform circulating nurse when you pack a wound, with what item,
and how many items are used.
Request count with any change of staff.
Ensure count is done at start of case, after leaving each cavity,
and upon skin closure. Remember you may need to tell the nurse
you need to do a count (he/she may not know, for example, that
you are leaving a cavity).
If the post-procedure count is off, then:
• Make a visual inspection of the operative area.
• Do a manual search of the operative area.
• Obtain x-ray and have it read STAT by the radiologist.
• Make sure the x-ray taken includes all the operative fields in
question.
• Document all measures taken.
The practitioner who orders the x-ray must follow up and read
both the body and conclusion of the official radiology report. This
is in addition to any verbal reports taken over the phone or in per-
son.
Consider routine intraoperative radiographic screening in select-
ed, high-risk categories of surgical procedures (obese patients,
closed-to-open procedures, emergent cases, and unexpected
change in surgical procedures).16
All surgeons should be educated and trained in the appropriate
and standardized sponge and instrument count procedures.17
All surgeons should know and adhere to the institution’s policies
and practices for sponge and instrument counting.17
Ann Surg 1996;224:79-84.
6
Ibid p 80.
7
Gawande A, Studdert D, Orav EJ, Brennan
TA, Zinner MJ. Risk factors for retained instru-
ments and sponges after surgery. N Engl J Med.
2003;348:229-35.
8 15
Ibid p. 230.
Ibid p. 229.
10
Ibid p. 232.
11
AORN Online Journal; November 2000:
Clinical Issues http://www.aorn.org/jour-
nal/2000/nov2kci.htm. Accessed October 16,
2005.
12
Reno D, Lobb J. Recommended practices
for sponge, sharp, and instrument counts.
AORN Recommended Practices Committee. In:
Hospital Staff (Nurses and Surgical Assistants)
Count all items, even prepackaged items.
Count at start of procedure, after each cavity is closed, at
skin closure, and following any change in staff.
Make sure any x-rays ordered are documented and co-
signed, films are sent promptly for a STAT interpretation
by the radiologist, and that the indication for why the film
is being done (such as to rule out a retained sponge or
needle) is made known to the radiologist.
Check kick-buckets and trash cans before initiating
sponge and instrument counts.17
Enforce quiet or dedicated time during the final counts so
nurses performing them are not disturbed.17
Conduct observational study of count process to learn
vulnerabilities, identify specific distractions, and improve
process design.17
Maintain continuity whenever possible by having the
same team or OR staff start and complete a case. When-
ever possible, lengthen assignments for consistency.17
Annually, assess staff competencies on the management
of sharps instruments, and sponges.17
*Text in the table above (unless otherwise noted with reference num-
bers) has been used with permission from the University of Florida
Self-Insurance Program/Risk Management and Loss Program.
2000 standards, recommended practices and
guidelines: with official AORN statements. 1st
ed. Denver, Colorado: Association of operating
room nurses; 2000:213-219.
13
Ibid p. 213.
14
Ibid p. 215.
Gibbs VC. Case & Commentary. Did we
forget something? AHRQ Web M&M: Case
Commentary. http://www.webmm.ahrq.gov/
case.aspx?caseID=27 Accessed October 9, 2005.
Gawande A, Studdert D, Orav EJ, Bren-
nan TA, Zinner MJ. Risk factors for retained
instruments and sponges after surgery. N Engl J
Med. 2003;348:234.
VA National Center for Patient Safety:
http://www.patientsafety.gov.
Radiologists
Ask for additional information if you need it:
• what item,
• what quantity; and
• likely location.
Get repeat films and over penetrated films as needed. (This
may help in identification of items located behind dense
organs.)
Call all “significant” findings directly to the attending sur-
geon.
Requests for stat X-rays in the OR for surgical cases with an
incorrect count should include:
• Type of procedure;
• Surgical site;
• Surgeon, and
• Nature of missing item.
Stat intra-operative X-rays should be jointly or sequentially
reviewed and discussed by the surgeon and the radiologist.17
Recognition of retained bodies after surgical procedures
should be an integral part of residency training in radiology.17
Ensure that portable X-ray machines can provide adequate
imaging data to meet the needs for assisting with identifica-
tion of retained items.17
PATIENT SAFETY FALL 2005 5

Interesting Resources To Explore
Health Affairs – Web Exclusive
www.healthaffairs.org/WebExclusives.php
“The Complex World of Military Medicine:
A Conversation with William Winken-
werder”
Dr. Winkenwerder, Assistant Secretary of
Defense for Health Affairs, engages in a wide-
ranging discussion of the military health-
care system. He discusses strategies for pro-
viding care on the battlefield and at home,
and comments on clinical quality efforts.
Ready, Set, Patient Safety
www.hcpro.com
Book referenced in ”Patient Safety In
Action” feature of this Newsletter containing
suggestion for patient safety Jeopardy game.
A wide variety of entertaining training
methods are included in the text. $129.00
Patient-Centered Resources
Agency for Healthcare Research
http://www.ahrq.gov/consumer/guidetoq
Guide to Health Care Quality: How To Know
It When You See It
Booklet released by the Agency for Health-
care Research and Quality in September as
part of its consumer education campaign to
help people take a more active role in their
own health care. Guidance on talking to
doctors, understanding health care quality
and finding quality information. Online at
the above address; order free single copies at
301-427-1244.
Institute for Healthcare Improvement
www.ihi.org
“Quality Allies: Improving Care by Engaging
Patients”
An ambitious national program funded by
Patient Safety
Awards
Submissions Deadline: Nov. 30 th, 2005
T
he third annual DoD Patient Safety
Awards will be presented at the
2006 TRICARE Conference in Jan-
uary. MTFs are encouraged to submit
projects for consideration by November
30, 2005. Award recipients will be notified
6 FALL 2005 PATIENT SAFETY
PATIENT SAFETY LINKS
the Robert Wood Johnson Foundation and
directed by IHI to define and spread best
practices in patient self-management sup-
port.
National Quality Forum
www.qualityforum.org/
“Improving Patient Safety Through
Informed Consent for Patients With Limit-
ed Health Literacy”
Wu HW, Nishimi RY, Page-Lopez CM, Kizer,
KW
Go to “Project Summaries” on website for
report on the experiences of four hospitals
that successfully implemented NQF Safe
Practice 10 – which calls for improved com-
munication in the informed consent process
– focused particularly on patients with lim-
ited health literacy. The report contains key
lessons learned and recommendations to
assist providers in implementing SP 10.
Disclosure and Error Reporting
Archives of Internal Medicine
http://archinte.ama-assn.org/
“Disclosing Harmful Medical Errors to
Patients”
Gallagher, TH, Levinson W., 2005;165:1819-
1824
Commentary provides an overview and per-
spective on the challenging issue of disclo-
sure of medical errors; advocates a proactive
approach, including developing guidelines
for disclosure and incorporating these prac-
tices into existing quality improvement ini-
tiatives. Includes a lengthy bibliography on
error disclosure.
Patient Safety Network
http://psnet.ahrq.gov
in December 2005.
Established to recognize leadership
and innovation in quality, safety and com-
mitment to patient care, the Patient Safety
Awards are presented in the categories of
Technology, Policy/Procedure and Team
Training. To be eligible for an award, a
project or initiative must demonstrate
that it has been tested and proven to
reduce errors, improve patient safety and
outcomes. Projects must be data driven,
practical, creative and transferable across
“The National Medical Error Disclosure and
Compensation (MEDIC) Act”
S.1784, 109th Cong., 1st Sess. (2005)
Bill introduced to Senate by Senators Clinton
(D-NY) and Obama (D-IL) in Sept, 2005 to
establish a program requiring hospitals to
disclose errors to patients and offer financial
settlements where appropriate; create a
national patient safety database; and protect
statements about and apologies for errors
from use in malpractice actions. Full text of
legislation can be accessed from this link.
American Medical News
www.amednews.com
“Patient Safety Gets Boost From Law Easing
Fear Of Reporting”
August 15, 1005;Vol 48, No 21: 1-2
Description of the federal Patient Safety and
Quality Improvement Act of 2005, signed
into law in August. Statute directs DHHS to
certify Patient Safety Organizations and a
system through which healthcare providers
can confidentially report errors. Reports will
stay confidential and cannot be used in
criminal, civil or administrative actions. See
http://thomas.loc.gov/cgi-
bin/bdquery/z?d109:s.00544 for statute.
Center for Urban Policy and the Environ-
ment, Indiana University Pudue University
www.urbancenter.iupui.edu.
“Medical Error Reporting System Could
Boost Patient Safety”
Ebright PR, Rapala K., September 2005:1-7
Issue brief outlines the importance of devel-
oping a state medical errors reporting sys-
tem in Indiana; factors that should be con-
sidered; and general characteristics of a good
state reporting system.
the Military Healthcare System.
Detailed information on project guide-
lines and evaluation criteria is posted on
the homepage of the DoD Patient Safety
Website: https://patientsafety.satx.disa.mil.
The Patient Safety Award Submission
Package, containing a project timeline and
templates for use, can be downloaded from
the site. A review of the projects awarded
recognition in the past can be found in the
2004 and 2005 Winter Newsletters, which
are archived and accessible on the website.
 PATIENT SAFETY IN ACTION
Experiences and Suggestions From the Field

51st MDG Patient

Safety Jeopardy
What is a Great Patient Safety
Teaching Tool?

o say patient safety at the 51st MDG,

T Osan Air Base, Korea is all fun and

games might be something of an
overstatement, but in fact, their own version
of Jeopardy has staff thoroughly enjoying a
challenging review of patient safety basics.
Developed by Patient Safety Manager Karen
Sutton, this interactive computerized ver-
sion of the familiar television game show
has proven an especially creative and popu-
lar approach to patient safety training.
The idea for the Jeopardy game came
from Ready, Set, Patient Safety, a training
book available from HCPRO, (see Links sec-
tion of this newsletter, page 6, for more
information). Ms. Sutton adapted the paper
version of the Jeopardy game suggested by Samples of
the book. She added a medical team training the Patient Safety
Jeopardy game.
category, and turned the exercise into an
interactive, entertaining experience com-
plete with sound and music. Not surprising-
ly, she chose the theme song from MASH as
the sign-off tune!
The game is easy to play. Staff simply
open up the Power Point slide show and click
“view show”. On slide two, they pick a cate-
gory, and click once for text and accompany- safety monitors for use in their respective and teams from hospital departments will
ing Jeopardy music. The next click will elicit areas via email; a separate link was sent out compete for prizes and the singular honor of
a buzzer sound and the Jeopardy answer, in to all hospital personnel summarizing the being named Jeopardy Patient Safety Grand
the form of a question, of course! The arrow game and identifying the file location for Champion.
key navigates staff through the game’s cate- access. Additionally, Ms. Sutton incorporat- At the 51st MDG, the focus on patient
gories, while a click on “exit” leads directly to ed the Power Point presentation into the safety training is serious, but the way in
the final slide and the farewell music. Newcomers Orientation, which all new which it is accomplished makes room for
Ms. Sutton, an experienced patient safe- employees are required to attend within simple, interesting and fun exercises. In Ms.
ty manager assigned to Osan AB since thirty days of their arrival. Sutton’s experience, this is the best way for
November, 2003 (now at Lakenheath AFB, Staff reaction has been enthusiastic. information to be remembered and
England) credits senior leadership support Rather than “just another power point brief- reviewed regularly. We are pleased to share
as a major key to the success of the Jeopardy ing”, they have reported “pleasant surprise” this patient safety Jeopardy game from the
game. She previewed the game to senior at the fun they’ve had with the quiz-show 51st Medical Group of “Combat…Medics”
leadership at an Executive Committee meet- format. To date there has been no formal located at the “Tip of the Spear”.
ing. With their blessing, the game has been competition within the hospital, but plans You can play the 51st MDG Jeopardy
widely distributed throughout the hospital. are afoot to hold a Jeopardy tournament as game by accessing the DoD Patient Safety
It was featured in the bi-monthly medical part of National Patient Safety Week activi- Website and following the appropriate links.
group newsletter; electronic copies were dis- ties this coming spring. A Final Jeopardy For specific information, contact Karen Sut-
tributed to hospital leaders and to patient question will be added to the presentation ton at KSutton823@aol.com.

PATIENT SAFETY FALL 2005 7

Patient Safety
Program Tools
Continued from Page 2
significant error rate in the medication use
history obtained by physicians in both ambu-
latory and in-patient settings. Over half of all
medication errors occur at transitions of
care, when medication orders are written
during admissions, discharges and transfers
within the health care system. Thus develop-
ment, reconciliation and communication of
an accurate medication list throughout the
continuum of care are essential for the reduc-
tion of transition-related adverse drug events.
To achieve this goal, JCAHO has imposed
two requirements: first, implementation of a
process, with patient involvement, for obtain-
ing and documenting a complete list of cur-
rent medications upon admission; second,
communication of a complete list of patient’s
medication to the next provider.
As CERPS explains in its Introduction for
Health Care Providers, (to be posted on the
Patient Safety website) medication reconcili-
ation is a systematic process designed to
improve communication during transitions
of care by creating a current, accurate, single
source medication profile for use by all health
care providers dealing with a specific patient
at the time any form of care is provided. Rec-
onciliation consists of three basic steps:
1. Collect and verify a current accurate med-
ication profile, including name, dosage,
frequency, route, and, if possible, time of
last dose
2. Use profile as basis when writing med-
ication orders
3. Reconcile by comparing patient’s current
profile against medication orders written
at admission, transfer and/or discharge
The DoD Military Health System (MHS)
has the unique advantage of a common
source of medication information in the
Composite Health Care System (CHCS).
NNMC Bethesda has provided a template for
utilizing the CHCS system in implementing
the medication reconciliation process. CHCS
captures all out-patient prescriptions pro-
vided through DoD pharmacies. As MTFs
begin to develop and formalize their respec-
tive reconciliation processes, access to exist-
ing CHCS profiles is a logical first step. At the
time of admission, information from CHCS
can be obtained, providing a base-line list of
medications for any given patient. This list
can form the basis of JCAHO’s mandated 8A
8 FALL 2005 PATIENT SAFETY
review with the patient/family to create an
accurate and full-range list of medications
upon admission.
All in-patient medication orders are
recorded in CHCS, thus augmenting a
patient’s profile. This information is avail-
able at the time of any inter-hospital
unit/care transfer. At discharge, a final med-
ication list can be generated and compared
with the admission profile to ensure that the
patient understands any changes in medica-
tions, and that there are no prescription
duplications or medication omissions. The
patient should be provided with this final
medication profile to include in his/her
medical record and bring to ambulatory vis-
its. The expectation of JCAHO requirement
8B, that the complete list of medications be
communicated to the next provider, can
more easily be met using CHCS data.
The medication reconciliation process
has been demonstrated to be a powerful
method for reducing medication errors. In
addition, medication reconciliation has been
shown to improve work efficiency, saving
time at admissions, transfers and discharge.
In the MHS, using CHCS to manage medica-
tion reconciliation will allow providers to
continue or discontinue medications already
in the system without re-writing orders at all
points during the in-patient period. Only
new medication orders will need to be writ-
ten. The resulting reduction in writing and
transcription will not only save time, it will
significantly reduce the opportunity for
medication order error.
Adopting a formalized medication rec-
onciliation process at each MTF, while neces-
sary to comply with the new JCAHO man-
dates, will bring DoD facilities closer to insti-
tutionalizing and realizing the “five rights” of
safe medication use: the right patient will
receive the right medication, at the right
doses, at the right time, by the right route.
Additional information, supporting instruc-
tions and training materials will be available
to all MHS facilities on the Patient Safety
website in early December. Information
compiled by Navy Medicine is currently
posted on the RITPO website:
https://ritpo.satx.disa.mil/mail.asp?a=8.
Particular recognition for this medica-
tion reconciliation solution should go to Ms
Roberta Williams, Ms Suzie Farley, NNMC
Bethesda, Dr. Eric Marks, USUHS, CDR Jef-
frey Blice, Chair of the NNMC Pharmacy
and Theraputics Committee and CAPT
David McCarthy, BUMED and the BUMED
Risk Management staff.
PATIENT
SAFETY
Patient Safety is published by the Department of
Defense (DoD) Patient Safety Center, located at the
Armed Forces Institute of Pathology (AFIP). This
quarterly bulletin provides periodic updates on 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
Please forward comments and suggestions
to the editor at:
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:https://patientsafety.satx.disa.mil
E-Mail to editor: poetgen@aol.com
DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM:
LTC Steve Grimes
DIRECTOR, PATIENT SAFETY CENTER:
Geoffrey Rake, M.D.
SERVICE REPRESENTATIVES:
ARMY:
Major Robert Durkee
NAVY:
Ms. Carmen Birk
AIR FORCE:
Lt Col Kathryn Robinson
PATIENT SAFETY BULLETIN EDITOR:
Phyllis M. Oetgen, JD, MSW
DoD PATIENT SAFETY WEBSITE
The DoD Patient Safety Website is accessible
at: https://patientsafety.satx.disa.mil. This
source of the most current information
about the Patient Safety Program and its
components is frequently updated, and
should be checked regularly. Features
include messages from the Director of the
Patient Safety Program, which review
accomplishments and announce new initia-
tives. The calendar of events lists all levels of
patient safety training offered by CERPS and
provides a link for registration. Patient Safe-
ty marketing and educational materials to
increase patient safety awareness among
patients and providers can be ordered from
the website. The Patient Safety Program
Tools are posted and can be downloaded
and adapted for individual MTF use. All
DoD patient safety providers are encour-
aged to make frequent access to the Patient
Safety Website a routine part of their prac-
tice protocol.