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Patient Safety Resource Guide Department of Defense Patient Safety Program

Partnering for a New Level of Care

Engaging, Educating and Equipping You with Products, Services and Solutions to Help Ensure the Safe Delivery of Care in the Military Health System

As a member of the patient safety community, the DoD Patient Safety Program strives to provide you with the resources, activities and solutions you need to deliver high-quality, safe care to each patient, every time. The Patient Safety Resource Guide was created to serve as a collection of evidence-based tools that readily complement and support the work you do in your programs and facilities every day. —Heidi B. King, Acting Director, DoD Patient Safety Program Director, Patient Safety Solutions Center

TABLE OF CONTENTS Getting to Know the DoD Patient Safety Program Mission and Military Health System Alignment

Advancing a Culture of Safety

Resources and Tools for Staff, Leaders and Patients

Equipping Teams for Performance in Safety and Quality

Resources for Teamwork Approaches using TeamSTEPPS®

Using Data to Guide and Drive Change Resources for Implementing Evidence-Based Safety Change Through Analyses

Getting On-Demand Access: Just-in-Time Resources Checklist of Communications Channels for Access Anytime

Simulating Real-World Events to Enable Feedback and Assessment

Tools to Enhance Safety using Simulation, Observation and Assessment

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Achieving the Aims of the Partnership for Patients Aims, Roles and Resources

Excelling as a Patient Safety Manager Patient Safety Training and Education

Measuring Patient Safety to Improve Patient Outcomes

Techniques, Tools and Services for Event Reporting and Measuring Harm to Create Sustainable Change

Staying Current with the DoD PSP: Regularly Scheduled Resources Checklist of the Communications Channels to Monitor

Partnering with External Organizations Connecting to Further Patient Safety Goals

Obtaining Continuing Education Credit Learning Activities Offering CEs

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4 Patient Safety Program: Partnering for a New Level of Care

Getting to Know the DoD Patient Safety Program


We support the military mission by building organizational commitment and capacity to implement and sustain a culture of safety to protect the health of the patients entrusted to our care.



The DoD PSP was mandated by the Floyd D. Spence National Defense Authorization Act of 2001 in an effort to ensure the safe delivery of healthcare to 9.6 million TRICARE beneficiaries across the defense health system.

The DoD PSP’s focus is to: Engage high-functioning teams focused on developing a culture of safety.

Our mission is to promote a culture of safety to eliminate preventable patient harm by engaging, educating and equipping patient-care teams to institutionalize evidence-based safe practices.

Empower providers with tools to enhance communications and teamwork.

We accomplish this mission by empowering healthcare professionals to make a difference for their patients through leadership engagement, training and education geared to varied professions and levels of personnel. In addition, we offer coaching, skill building, data interpretation, process improvement, risk assessment, task analysis and human factors consultation. By fostering a culture of patient safety through education and promoting trust and transparency, we can identify and mitigate risks to patients.

Activate patients in their health and healthcare. Make care safer for every military health patient.

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Patient Safety Program: Partnering for a New Level of Care 5



The DoD PSP equips Military Treatment Facilities with evidencebased products, solutions and capabilities to improve the safety and quality of care in the MHS. We provide these resources in support of the MHS Strategic Initiatives and the Quadruple Aim—Readiness, Population Health, Experience of Care and Per Capita Cost—for a medically ready force.


We encourage you to take a few moments to read the Patient Safety Resource Guide to gain awareness of the many resources available to you in support of your patient safety activities. In addition to the links provided within the guide, all resources referenced here and many others can be found on the DoD PSP website:


The annual Patient Safety Awards Program recognizes facilities that have shown innovation and commitment to the development of systems and processes that meet the needs of the patient. Additionally, the Partnership for Patients Recognition Program encourages leaders, peers and colleagues to acknowledge those individuals, teams and MTFs helping to drive the spread of required evidence-based practices and strengthen a patient safety culture of excellence. The resulting success stories and best practices are captured and disseminated through the DoD PSP eBulletin, DoD PSP website and case studies, among other channels.

THE QUADRUPLE AIM Enabling a medically ready force and resiliency of all MHS personnel. Improving quality and health outcomes. Advocating and incentivizing healthy behaviors. Managing the cost of providing care to the population. Eliminating waste and reducing unwarranted variation; reward outcomes, not outputs. Patient and family-centered care that is seamless and integrated. Providing patients with the care they need, exactly when and where they need it.

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6 Patient Safety Program: Partnering for a New Level of Care

Achieving the Aims of the Partnership for Patients Military health caregivers and personnel are driving system-wide improvement to accelerate the spread of evidence-based practices throughout defense health and reduce preventable hospital-acquired conditions by 40 percent and readmissions by 20 percent by 31 December 2013.


MILITARY HEALTH & THE PARTNERSHIP FOR PATIENTS INITIATIVE In April 2011, Department of Health and Human Services unveiled the Partnership for Patients: Better Care, Lower Costs, a public-private partnership that is helping improve quality and safety of healthcare across the nation. The DoD committed to the initiative, with the support and commitment of the Services, to make care for our Service men and women and their families safer, more reliable and more efficient. The Partnership for Patients supports MHS Strategic Initiative #2— Implement Evidence-Based Practices Across the MHS to Improve Quality and Safety—and provides a model for developing a transformative enterprise approach to care. PfP and its measureable aims to address specific aspects of improved patient care serve as a springboard for other comprehensive patient safety initiatives and organizational changes moving forward. As teams work to implement and sustain PfP goals, key personnel share leading practices and measurable results, as well as institute an integrated operational plan.

PfP AIMS • Aim 1: Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. Achieving this aim would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years. • Aim 2: Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased, such that all hospital readmissions would be reduced by 20% as compared to 2010.

IMPLEMENT AND SUSTAIN EVIDENCE-BASED PRACTICES PfP is helping drive the spread of EBPs across the Services and MTFs, reinforcing a patient safety culture of learning and performance improvement. The DoD PSP has developed tools to help plan, execute and improve patient care and safety at MTFs. • Implementation Guides The PfP Implementation Guides support the execution of selected EBPs for each harm condition and for readmissions. The guides outline the steps of each selected evidence-based practice, and the selected process and outcome measures for each harm category. • Performance Improvement Guide Using PfP as an example, the Performance Improvement Guide supports front-line change teams with practical knowledge and tools in performance improvement. It also serves as a companion document to the PfP Implementation Guides.

PfP Harm Categories • Adverse Drug Events • Catheter Associated Urinary Tract Infections • Central Line Associated Blood Stream Infections • Falls • Obstetrical Adverse Events • Pressure Ulcers • Readmissions • Surgical Site Infections • Ventilator Associated Pneumonia • Venous Thromboembolism

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Patient Safety Program: Partnering for a New Level of Care 7

A Learning Action Network series has also been established, and includes Learning Circles (webinars/workshops) and Communities of Practice. Learning Circles and other PfP-related webinars are available through-out the year. A schedule of upcoming sessions can be found at the DoD PSP Calendar of Events. CoPs were developed around clusters of MTF teams to share successes, best practices and resources to address specific PfP harm categories. Participation in CoPs is determined by, and coordinated through, the associated Service Patient Safety Representative. For more information about CoPs, contact

OTHER TOOLS For a simple, straight-forward reference to help explain what PfP and its tools can offer your patient safety and quality teammates, use the PfP Summary Slides. They can easily augment any presentation or serve as a hand-out during patient safety and quality meetings and staff events. The PfP Recognition Program gives peers, colleagues and leaders the opportunity to easily acknowledge the hard work and dedicated efforts of individuals, teams and MTFs spreading required evidence-based practices and reinforcing a culture of patient safety learning and performance improvement. Share a timely PfP “thank you� by completing a simple online form:

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8 Patient Safety Program: Partnering for a New Level of Care

Advancing a Culture of Safety


An organization with a strong safety culture demonstrates professionalism and the ability to learn from failure. Staff, leaders, patients and families take an active role. Staff exemplify the attitudes, beliefs, perceptions and values that demonstrate a relentless pursuit to provide safe, quality care for their patients. FOR PATIENT SAFETY LEADERS AND PROFESSIONALS: MEASURING THE SAFETY CULTURE Every three years, the DoD distributes the Tri-Service Survey on Patient Safety (Culture Survey) to all MTFs within defense health. This survey captures staff attitudes and beliefs about patient safety, medical errors and event reporting. The anonymous survey encourages all staff to communicate their perceptions so that leaders can identify strengths and opportunities for improvement in areas essential to a culture of safety, including communication, empowerment of frontline staff and collaboration among staff and units. A snapshot of the patient safety culture, it assesses staff perceptions of patient safety, medical errors and event reporting. Find more information, including information about the recent 2011 survey at

FOR PATIENTS: GROWING THE WILLINGNESS, CONFIDENCE AND KNOWLEDGE TO PARTICIPATE IN HEALTHCARE An activated patient possesses the willingness, confidence and knowledge to take an assertive, decision-making role in managing his or her own health and healthcare. Because activated patients are less likely to encounter an adverse patient safety event and more likely to engage in preventive behaviors, understanding a patient’s level of involvement can help the healthcare team customize a plan of care that encourages the highest-level of involvement the patient is comfortable with and one that has the greatest chance for improved clinical outcomes. The DoD PSP’s Patient Activation Reference Guide provides resources for patients, families, healthcare teams and MTFs to assist in moving patients forward on the patient-activation continuum. Your MTF can also participate in the Ask Me 3 patient education program, through the National Patient Safety Foundation, which is designed to promote communication between healthcare providers and patients to improve health outcomes. And, you can use the TEAM UP brochure to provide guidance on how patients can actively participate in their care.  

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Patient Safety Program: Partnering for a New Level of Care 9

Excelling as a Patient Safety Manager

There are many resources available through the DoD PSP for PSMs and other champions of patient safety, to include training, coaching, data analysis, webinars, reporting and measurement tools.


The PSM’s Role as a Leader

The BPSM course is a five-day, face-to-face training that provides new DoD PSMs in MTFs with the knowledge, skills and learning resources they need. Geared towards first-year PSMs, the course focuses on four key areas: • • • •

Understanding Service-Specific Patient Safety The PSM’s Role in Quality Management & Process Improvement

The PSM’s Role in Identifying & Mitigating Risk

Evidence-based practice and standards Leadership and change management Quality management and process improvement Identifying and mitigating risk

Throughout the course, new PSMs plan how they will put their knowledge into practice when they return to their MTFs through the completion of roadmap activities. Course participants network with experienced healthcare professionals and meet with their Service Patient Safety Representative. The course incorporates training on the TapRooT® Root Cause Analysis methodology, which PSMs use to conduct RCAs at their MTFs. (Training on TapRooT® software is conducted during follow-up webinars. Information on days/ times is provided during the BPSM class.) If you are a DoD PSM, you have the unique opportunity to engage with experts and other PSMs in this award-winning BPSM course.


Overall excellent program and enthusiastic, well-engaged staff. —Navy Participant


This course gives us in the field the tools necessary to be successful in our mission. Thank you for putting Patient Safety first. —Air Force Participant

Participants must be referred by their Service Patient Safety Representative. Contact your Service representative for upcoming class dates and registration information.

I thought this was an excellent seminar.

—Army Participant

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10 Patient Safety Program: Partnering for a New Level of Care



After the conclusion of BPSM training, participants join follow-up coaching sessions to support the adoption and sustainment of skills and desired outcomes. The DoD PSP also provides individual and/or group coaching for PfP Communities of Practice and TeamSTEPPStrained staff at MTFs. During these sessions, coaches work with an MTF to identify progress toward plans and goals, pinpoint and mitigate challenges and maintain continuous improvement efforts. To learn more about DoD PSP coaching, contact

Continuing education is as close as your computer. The DoD PSP has developed three ondemand eLearning modules that can bolster or refresh every PSM’s knowledge-base: •

PSM ONGOING LEARNING PROGRAM CERTIFICATE A commitment to professional growth and development is important as a PSM. The PSM Ongoing Learning Program Certificate recognizes PSMs within MTFs who demonstrate dedication to ongoing professional achievement in the field of patient safety. Contact the DoD PSP at to learn how to qualify for this certificate.

Patient Safety Reporting System v1.01 eLearning Module: Designed for all levels of MTF staff, this self-paced module describes the basic navigational and functional features of the PSR system, as well as the roles and responsibilities of PSR users. Patient Safety Reporting: Intermediate Course eLearning Module: This self-paced module is intended for PSMs and other MTF staff already familiar with basic functionalities of the PSR system. The course is designed to help learners develop the decision-making skills needed to effectively manage patient safety event data in PSR, in the ongoing effort to eliminate preventable harm at MTFs. Root Cause Analysis eLearning Module: From the initial reporting of a patient safety event and the identification of contributing factors and root causes to the recommendation of corrective actions, this self-paced module outlines the DoD PSP’s suggested practices for conducting an RCA.

TEAMSTEPPS® MODULES New modules for Team Strategies and Tools to Enhance Performance and Patient Safety — known as TeamSTEPPS— have been added to further teamwork skills in three distinct areas: Primary Care Offices, Long-Term Care Settings and Enhancing Safety for Patients with Limited English Proficiency. Learn more at Have questions, comments or other input? Contact us at 703-681-0064, or via Facebook at

Patient Safety Program: Partnering for a New Level of Care 11


Equipping Teams for Performance in Safety and Quality In the dynamic environment that we operate in each day, patient safety depends on the coordinated interactions of individuals and teams committed to creating a safe patient experience. TEAMSTEPPS®

TeamSTEPPS is an evidence-based teamwork system designed to improve the quality, safety and efficiency of healthcare. TeamSTEPPS consists of a collection of instructions, materials and tools to help drive a successful teamwork initiative from the initial planning to implementation through to sustainment. The system is designed to improve patient safety using a three-phase approach:

One of my non-negotiable priorities is to uphold the quality of care in the Military Health System, guided by priorities and initiatives that are based on a sound foundation of evidence. TeamSTEPPS is supported with over two decades of research and lessons learned. It remains the Military Health System’s flagship initiative to improve teamwork, communication and the delivery of safe care to our beneficiaries worldwide. —Jonathan Woodson, M.D., Assistant Secretary of Defense for Health Affairs

• Phase I Assessment: Facility determines organizational readiness. • Phase II Planning, Training & Implementation: Facility “decides what to do” and “makes it happen.” • Phase III Sustainment: Facility spreads the improvements in teamwork performance, clinical processes and outcomes resulting from the TeamSTEPPS initiative.





Planning, Training & Implementation


Pre-Training Assessment SITE ASSESSMENT




Climate Improvement

Set the Stage


Decide What to Do


COACH & INTEGRATE Intervention



Make it Happen


Make it Stick



The DoD PSP can help you assess your readiness, create an action plan, support training and provide coaching to sustain continuous improvement in team behavior. Contact us at 703-681-0064 or



Culture Change

Situation Monitoring

Mutual Support






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12 Patient Safety Program: Partnering for a New Level of Care

Measuring Patient Safety to Improve Patient Outcomes

Given the challenge to reduce medical and dental errors and eliminate preventable harm, healthcare facilities must report and measure how many—and how often—errors occur. They also must measure their performance to show improvement over time. Reporting contributes to a just culture, knowing that you have the opportunity and the freedom to report what you are seeing without retribution. With accurate reporting, you can target actions to mitigate future risk to ultimately build resilience to improve patient outcomes.



PSR is a web-based, standardized reporting tool that enables anyone in the MHS with a Common Access Card to anonymously report a patient safety event or near miss. After an event is reported, the PSM reviews it and initiates an investigation to identify the factors that contributed to the incident and develops corrective actions that address those factors. Service headquarters and the DoD PSP analyze the reports to identify trends throughout the Services or defense health. It is important to understand that if you witness a situation, you should report it. What you report through PSR can lead to needed change and enhance safety in your workplace and for your patients. Download job aids and complete the training courses found on the Patient Safety Learning Center, which is accessible from the DoD PSP website. (To learn how to access the PSLC community, visit page 14.)

Research indicates that self-reported events represent only a small percentage of all adverse events within an organization. The DoD is studying the use of “triggers,” or clues, to identify adverse events used in determining the overall level of harm in our system. By tracking adverse events over time, we can detect if changes being made are improving the safety of the care processes.

All levels of the DoD Harm Scale should be reported. Whether a near miss or sentinel event, it is imperative that all events are captured and reported for analysis. Near misses, in particular, can identify organizational or systemic weaknesses before a patient is harmed.

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The reporting of every harm event, including near misses, represents an opportunity to improve patient safety, enhance the patient experience, ensure readiness and cultivate population health, as well as meeting the goals of the Quadruple Aim and creating a safer care environment for every patient during every interaction —Mr. Michael Datena, Director, Patient Safety Analysis Center

Patient Safety Program: Partnering for a New Level of Care 13

Using Data to Guide and Drive Change You can be the catalyst that drives change. Events occur. Learn from reported adverse events and near misses by identifying causal factors and establishing measures to prevent reoccurrence. Using retrospective and prospective analyses, it is possible to mitigate preventable harm. PROACTIVE RISK ASSESSMENT ANALYSIS Data Interpretation and Consultation Services We encourage you to request assistance with your specific data interpretation needs. The DoD PSP provides consultation in the areas of process improvement, environmental risk assessment, task analysis and human factors. We can help you use PRA to drive the change you need, isolate data to identify trends and generate ad hoc reports from PSR to answer leadership questions, RCA-based queries and more.

Success Story An MTF identified a trend in near misses that led up to an actual event—misreading an EKG machine. Because they identified this trend early, they prevented harm from reaching the patient. The facility identified why the malfunction in the equipment occurred and a temporary fix was implemented until the manufacturer changed the way the equipment was labeled.


PRA is a process that helps identify and mitigate risks and hazards. It includes Failure Modes and Effects Analysis, a technique that involves identifying potential problems (failures), ranking the severity of the failures and identifying ways to prevent them. TapRooTÂŽ methodology and software can be used by PSMs to conduct PRAs.

ROOT CAUSE ANALYSIS RCA is a structured method used in the DoD to understand the causes of sentinel events occurring in MTFs. Service headquarters may also recommend an RCA on an event that presents a significant risk to the patient population. RCAs are based on the premise that medical errors result not from individual error, but from systemic process and structural failures. The RCA process helps identify those factors that contribute to errors. RCA teams answer specific questions to determine the strongest corrective actions possible. PSMs also use TapRooT to conduct RCAs and develop a corrective action plan to mitigate future risk. To access on-demand RCA training, click here.

FOCUSED REVIEWS Focused Reviews present patient safety case scenarios and topics, findings, root causes and recommendations for strong corrective actions. These actions are most likely to reduce the probability that the mistake will reoccur. They can be accessed through the PSLC.

OTHER RESOURCES The Data Pulse is published monthly and offers a Tri-Service snapshot of PSR data, such as events by degree of harm, month and type, location type and cumulative reporting for the DoD, as well as monthly focus areas such as specific Partnership for Patients topics. It can be accessed through the PSLC. The Sentinel Event Watch is a monthly publication provided to leadership with two overarching principles: near real-time distribution of sentinel event data and inter-Service transparency of this information. It includes focuses on a specific sentinel event category(ies) and emerging trends. Associated causal factors and corrective actions are included to facilitate awareness and learning and encourage risk-mitigation. It can be accessed through the PSLC.

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14 Patient Safety Program: Partnering for a New Level of Care

Getting On-Demand Access: Just-in-Time Resources The DoD PSP is always “on call,” ready to equip you with the tools you need to drive a culture of patient safety and performance improvement at your facility daily.

Visit the DoD PSP Website

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Interact and Stay Informed with the Pat ient Safety Learning Center

The PSLC is a protected memberbased online com munity wiki that enables patient safety personnel to access and share best practices, tools, news articles, learning activities and more. Any one engaged in patient safety activities from the military Ser vices can request access to the PSLC and become an active collaborator in a secure environment. Submit a request for access via website.

Toolkits Download Patient SafetyDo e inD PSP offer just-in -tim

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DoD PSP Facebook Page

By sharing program offerings and tools, promoting partner resources and engaging the pati ent safety community across the defense health syst em, the DoD PSP’s Facebook page highlights news and updates relevant to patient safety and expands stakeho lders’ awareness of the DoD PSP.

Medication Follow the Alerts, Advisories and Safety Notices the PSLC to stay abreast and Use the DoD PSP website ries and medication safety iso adv , of the latest alerts ety Analysis Center, Instinotices from the Patient Saf ctices, Joint Commission, tute for Safe Medication Pra Food and Drug Adminis Air Force Notices to Airmen, tion, Clinical Operations tration, Aeromedical Evacua re. Patient Safety Acts and mo

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Patient Safety Program: Partnering for a New Level of Care 15

Staying Current with the DoD PSP: Regularly Scheduled Resources


Engaging in the patient safety community by sharing news and participating in activities helps sustain momentum. Access these learning opportunities to continue your patient safety education. These resources are available via the DoD PSP website and the PSLC, described on the previous page.

ing Circles and Workshops Attend Patient Safety Learn person webinars ny online and inThe DoD PSP hosts ma Continuing which are approved for of and workshops, some r tte ma ct tated by subje Education credits. Facili rch, share the latest resea s tie tivi experts, these ac patient t ou ab d rne lea d lessons emerging practices an ip safety culture, leadersh safety. Topics include re. Register mo d an n tio ven pre error engagement, medical events. of r PSP’s online calenda for events via the DoD hives arc the t ou sentation, check If you miss the live pre LC. PS the d an ite bs DoD PSP we online, available on the

Subscribe to the DoD PSP eBulletin via

□ □ About the Learning Update Welcome to the DoD Patient Safety Program Learning Update. This update is distributed monthly and provides information around patient safety learning activities. While the update will mostly highlight activities coming up in the next month, we will sometimes add important reminders for other high priority learning and networking opportunities. We encourage you to share this update with your colleagues.

Patient Safety WorkShoPS

Instructor-led or self-paced online learning sessions focused on a specific product

No activities in November

Patient Safety Learning CirCLeS In-person or web-based forums focused on a specific topic

November 8, 1400-1500 ET Introducing Patient Safety Reporting (PSR) 11.2* Click here to register This activity is for DoD only November 14, 1400-1500 ET Safe Care Saves Lives: Planning and Implementation for Performance Improvement* Click here to register This activity is for DoD only November 15, 1400-1500 ET Data Dialogue: DoD PSP FY2012 Midyear Summary Review* Click here to register This activity is for DoD only November 15, 1400-1500 ET The Evolution of Safety across the Continuum: Is Ambulatory Safety the Missing Link?* Click here to register** * Denotes that activity eligible for CE credits. All CE credits are provided and maintained by Duke University Health System. **Did you know? As an NPSF Stand Up for Patient Safety member, DoD PSP receives discounted congress registration as a benefit of program membership. Check with your facility POC for more information.

Patient Safety ConneCtion In-person networking and leading practices discussions

No activities in November

Patient Safety heLPLineS

One-on-one sessions available to stakeholders

No activities in November

Don’t wait to register for other PSP activities! Click here to view the 2012 PSP Calendar: Do you have a learning activity or networking opportunity that should be included? Email us here: to subscribe to have the Learning Update delivered to your inbox each month, go to:


Deliver y The DoD PSP eBulletin is a monthly electronic newsletter that provides patient safety upd ates, news, tips, success stories and upcoming eve nts. Click here to subscribe now.

very arning Update via GovDeli t tha n Opt-in to the DoD PSP Leda tio ca bli pu r te is a regula Up The DoD PSP Learning activities patient safet y learning of provides a summary w. no be re to subscri through email. Click he

P Data Pulse er vice Check the DoD PS a monthly, Tri-S fies a Pulse of fers at assi The DoD PSP D ent data that cl and sentinel ev R tion PS ca of lo , ot pe sh ty snap onth and m , rm ha of ee . It can be events by degr rting for the DoD po re e iv at ul m type and cu h the PSLC. accessed throug

Read Annual Summaries

Annual Summaries provide an analysis of patient safety events (medication and non-medication), RCAs, PRAs and other reports that were submit ted by the Services. They identify trends, lessons learned and other observations impacting the safety of patient care and can be accessed through the PSLC.

Study the Focused Reviews

Focused Reviews present patient safety case scenarios and topics, findings, root causes and recommendations for strong corrective actions. Rec ent issues have included such topics as “Unders tanding and Measuring Patient Safety,” “Dental Patient Safe ty” and “Patient Safety in Aeromedical Evacuation . They can be accessed through the PSLC.

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16 Patient Safety Program: Partnering for a New Level of Care

Simulating Real-World Events to Enable Feedback and Assessment Simulation-based training with formal feedback mechanisms helps to assess, train and sustain high-performing teams.

SIMULATION-BASED TRAINING The DoD PSP collaborates with MTFs and simulation centers to provide simulation as an adjunct to training or to enhance skills and knowledge. There are a wide-range of options, including opportunities for teams to use low-fidelity simulations and role-play activities to strengthen teamwork skills, mannequin-based patient simulators, Mobile Obstetric Emergencies Simulation and simulation scenarios and environments for a spectrum of medical emergencies and wartime and battlefield scenarios. Some MTFs are routinely using simulation for training and skill practice, and many are using situation-specific simulation, such as the operating room. The National Capital Area Medical Simulation Center is one of the simulation centers that provides the Services with a wide array of training tools—from simulated clinical exams using live patients, to task trainers designed to improve skills, to the Wide Area Virtual Environment for training combat medical and surgical teams. The DoD PSP participates in the Federal Medical Simulation Training Consortium. The FMSTC is focused on enhancing the medical education and training practices through joint collaborative sharing in research and development, knowledge management, curriculum, validation and strategic partnership. If your MTF is interested in accessing simulation training, contact your Service Patient Safety Representative.

OBSERVATION AND ASSESSMENT TOOLS Medical Team Performance Assessment Tool Practice alone is not enough to ensure learning from experience. Learners must receive accurate, timely and improvement-focused feedback. MTPAT, a tablet-based software application, enables the capture of team performance in live and scenario-based medical environments to provide behavior-based qualitative and quantitative feedback and track performance improvements. This tool was developed by Naval Air Systems Command with the support of the DoD PSP.

Team Effectiveness Accelerator TEA, a web-based assessment tool, enhances teamwork skills by capturing information and feedback from team members after completion of a simulation exercise or work experience. The tool produces a customized guide that a facilitator uses to lead a debrief or an after-action review. This tool was developed in partnership with the Group for Organizational Effectiveness, Inc. and Naval Air Warfare Center Training Systems Division with support from the DoD PSP. Have questions, comments or other input? Contact us at 703-681-0064, or via Facebook at



Patient Safety Program: Partnering for a New Level of Care 17

Partnering with External Organizations

Achieving safety for our patients requires the commitment of organizations and individuals across the DoD, Services, industry and academia. For this reason, the DoD PSP partners with Federal agencies, not-for-profit organizations, educational institutes and civilian healthcare organizations. FEDERAL AGENCIES

The DoD PSP interacts and engages with Federal agencies, including the Veterans Health Administration’s National Center for Patient Safety, the Agency for Healthcare Research and Quality and the the Centers for Medicare & Medicaid Services, as well as other leading organizations in the patient safety field. These partnerships enable cross-sharing and collaboration.

NOT-FOR-PROFIT ORGANIZATIONS The DoD PSP also partners with not-for-profit organizations, such as the National Quality Forum, the Joint Commission and the National Patient Safety Foundation. The DoD PSP is a member of both the NPSF’s Stand Up for Patient Safety and Ambulatory Stand Up for Patient Safety programs, through which DoD facilities have access to data comparisons, resource guides, online information and webcasts. NPSF also sponsors the annual Patient Safety Awareness Week campaign, enabling MTFs and PSMs to promote patient safety practices and resources directly to the care teams and patients at their facility.

EDUCATIONAL AND HEALTHCARE ORGANIZATIONS The Institute for Healthcare Improvement and the Institute for Safe Medication Practices are examples of organizations that we leverage for their outstanding subject matter expertise. Through the DoD PSP relationship with ISMP, the Services gain access to the electronic medication safety newsletters for healthcare professionals and consumers, including the ISMP Medication Safety Alert: “Acute Care,” “Community Ambulatory Care” and “Safe Medicine” editions. The newsletters are accessible through the PSLC.

TEAM RESOURCE CENTERS TRCs conduct fundamental applied research on teamwork and they develop, pilot and validate tools to improve patient safety. The TRCs also conduct training and disseminate their research findings. TRC sites include the Army Trauma Training Center, FL; Andersen Simulation Center, Madigan Army Medical Center, WA; Naval Medical Center Portsmouth, VA; and David Grant Medical Center, Travis Air Force Base, CA. If you interested in accessing the resources of a TRC, contact your Service Patient Safety Representative.

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18 Patient Safety Program: Partnering for a New Level of Care

Obtaining Continuing Education Credit


The completion of continuing professional education has long been used to demonstrate professional growth. Courses that are eligible for CE credits are designed to help individuals improve and enhance their knowledge, skills and talents. CE credits are not just a requirement for professionals to renew or maintain their licenses, but they also enable you to learn about new and developing areas in the medical and dental fields.

WHY EARN CE CREDITS THROUGH THE DoD PSP? Healthcare is constantly changing, as are the dynamics within the realm of patient safety. Consider the DoD PSP your fundamental resource for educational opportunities that address current and emerging issues within the world of patient safety. Participation in the CE-credited DoD PSP learning activities reinforces your commitment to remain current with the evolving issues and technologies related to patient safety.

WHICH EDUCATIONAL ACTIVITIES QUALIFY FOR CE CREDIT? 1. Learning Circles. The DoD PSP believes in the value of the topics discussed and knowledge exchanged during our webinars and workshops. Some of these qualify for various CE credits. Check individual session descriptions for further details. 2. Self-Paced Focused Reviews. Understanding the value that Focused Reviews bring to the MTFs, the DoD PSP has also invested in offering CE credits for your participation in self-paced study of Focused Reviews. Check individual course descriptions for details and requirements.

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Patient Safety Program: Partnering for a New Level of Care 19

3. Instructor-Led Training. The DoD PSP places much emphasis on the value of instructor-led training and provides CE credits for your participation in both TeamSTEPPS courses and the BPSM course. Check individual course descriptions for details and requirements. 4. On-Demand eLearning Courses. The DoD PSP also provides mission critical learning through elearning courses that can be accessed wherever an Internet connection is available. Some of these courses offer CE credits. Check individual course descriptions for further details.

WHO CAN RECEIVE CE CREDIT? To receive CE credits, you must register for, attend and complete all required hours of a CE-credited course, which includes completing and submitting the associated course evaluation within 10 days. The following types of credits may be available through our CE provider for various DoD PSP learning activities: • Continuing Medical Education for Physicians • American Nurses Credentialing Center Nursing Contact Hours • American College of Healthcare Executives for Healthcare Executives • American College of Physician Executives for Pharmacists • International Association for Continuing Education & Training Continuing Education Units* (all other professions) *It is important to note that CEUs are calculated at .10 value of other credits.


HOW DO I RECEIVE CE CREDIT? It is simple. Once you have registered for your credit-approved course or learning opportunity through the Online Registration Center: 1. Attend all training hours for the scheduled course. Arriving late or departing early makes you ineligible for CE credits. Attendance is tracked and audited by our CE provider. 2. Submit a post-course evaluation within 10 days of completing the course. The window for course evaluations closes after 10 days, and you will not be able to submit an evaluation after that deadline. 3. Request a CE during registration. Failure to select the type of CE will preclude you from receiving a CE credit. After you have registered, completed the course, and completed the associated course evaluation within the prescribed time, your CE certificate will be issued. Have additional questions about the CE process? Contact the ORC/CE Team at

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20 Patient Safety Program: Partnering for a New Level of Care

We hope the products, services and solutions highlighted in this Resource Guide will help you ensure the safe delivery of military healthcare. We encourage your participation in using the resources highlighted within this Resource Guide. Please contact us if you have any recommendations for future versions of this Resource Guide.

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