INSIDE: WRIGHT-PATTERSON RECORDS REVIEW SYSTEM

Patient FALL
F00112004
Page 3 Safety Goal Actions

Safety
Page 4 Timely Links
Page 5 Project News Share
Page 6 JCAHO Campaign

A quarterly newsletter to assist DoD hospitals with improving patient safety

NATIONAL AWARD
PRESENTED TO
ARMY MAJOR
Distance Learning Program
Recognized
A rmy MAJ(P) Danny Jaghab
received the prestigious 2004
John M. Eisenberg Award for
Innovation in Patient Safety and
Quality on October 6th at the National
Quality Forum Annual Meeting in
Washington, D.C. MAJ(P) Jaghab was
honored for his MPEG Training
Program, a distance learning course
consisting of thirty-four scripts based
on Joint Commission patient safety
goals and recommendations which
MAJ(P) Danny Jaghab receiving the 2004 John M. Motion Picture Expert
Eisenberg Award from Kenneth W. Kizer, MD,
MPH, President and CEO, National Quality
Forum. Photo by: COL Paul Little, US Army
CHPPM.
provides comprehensive patient safety
training.
The award winning training program
was conceived by MAJ(P) Jaghab in
2003 when he was serving as Dietetic
Internship Director at Brooke Army
Medical Center. A registered dietitian,
MAJ(P) Jaghab had previously devel-
oped an MPEG series to promote the
Army’s five-a-day program for fruits
and vegetables. Recalling this experi-
ence as Brooke prepared for an antici-
pated Joint Commission on
Accreditation of Healthcare
Organizations (JCAHO) survey, MAJ(P)
Jaghab proposed the same format as
an effective and efficient way to pro-
vide hospital-wide training on the
JCAHO patient safety goals.
Creating the program was a
labor-intensive project. For
each patient safety goal and
recommendation, MAJ(P)
Jaghab developed three two-
to-four minute scripts,
describing a sentinel event,
outlining risk reduction
strategies, and reviewing rel-
evant local and Medcom
policies respectively. MAJ(P)
Jaghab narrated the scripts
on video, edited the tapes
and converted them into
Group (MPEG) format. He
asked key hospital leaders to
Continued on page 2
DOD PATIENT
SAFETY AWARDS
The submission deadline for the 2005
Patient Safety Award is November 17,
2004. Application documentation is
available on the DoD Patient Safety
Website:
https://patientsafety.satx.disa.mil.
2004 Award winners were highlighted
in the winter 2004 Patient Safety
Newsletter, which can be accessed on
the website.
Recipients of the Award will be noti-
fied on December 15, 2004. The
Award will be presented at the 2005
TRICARE Conference in January.
DoD 2005
PATIENT SAFETY
CULTURE SURVEY
The Department of Defense 2005
Patient Safety Culture Survey is sched-
uled for deployment within Army,
Navy, and Air Force military treatment
facilities (MTFs) in early 2005. The
web-based survey, sponsored and
funded by TRICARE Management
Activity (TMA), will assess staff opin-
ions about issues related to patient
safety in MTFs. Survey feedback
results will be provided to facilities
and can be used to raise staff aware-
ness about patient safety, to identify
areas for improvement, and to meet
requirements of the Joint Commission
on Accreditation of Healthcare
Organizations (JCAHO).
The kick-off for the survey will be
held at the annual TRICARE confer-
ence January 24-27, 2005. Further
details about the survey will be forth-
coming.

NATIONAL AWARD
PRESENTED TO
ARMY MAJOR
Distance Learning Program
Recognized
continued from page 1
lend their support to the project by
providing endorsements for each seg-
ment. The MPEGS were then posted
to the hospital intranet. Over three
thousand hospital staff received emails
on a regular basis to guide them
through the entire MPEG series. Each
email contained a photograph of a key
leader, his or her scripted endorse-
ment, and a link to a designated MPEG
learning module. Staff members who
watched all thirty-two MPEGS were
provided with a certificate of patient
safety training. Immediate positive
feedback for the program was provid-
ed by the JCAHO surveyor in
December, 2003 when he commended
MAJ(P) Jaghab’s effort as an example
of best practices in patient safety
training.
Recognition of the MPEG program by
the National Quality Forum gives
MAJ(P) Jaghab’s initiative a national
identity, and places it in the company
of leading patient safety advocates.
The National Quality Forum (NQF) is a
private, not-for-profit organization
Recipients of the 2004 John M. Eisenberg Awards, with Dennis S. O’Leary,
MD, JACHO, Mrs. Eisenberg, and Kenneth Kizer, MD, National Quality
Forum. Photo by: COL Paul Little, US Army CHPPM.
whose open membership
represents broad participa-
tion from all parts of the
healthcare system. In 2002
the National Quality Forum
and the Joint Commission on
Accreditation of Healthcare
Organizations launched the
John M. Eisenberg Patient
Safety and Quality Awards.
The awards honor the memo-
ry of Dr. Eisenberg, a highly
respected national leader in
healthcare quality, and
Director of the Agency for MAJ(P) Danny Jaghab with his family: wife
Healthcare Research and Delmy, son, Danny and daughter, Jasmine at the
Quality (AHRQ) from 1997 John M. Eisenberg Awards ceremony in
until his untimely death in Washington, D.C.
March, 2002.
Quality on the local level for a series
This year, in addition to MAJ(P) Jaghab,
of creative teaching/learning packets
Eisenberg Award recipients included
entitled “Keeping Each Patient Safe”.
Lucian L. Leape, MD, for his individual
achievement as a leader of the patient
All award recipients attended the
safety movement; and Peter J.
National Quality Forum meeting in
Pronovost, MD, PhD, for his research
October, and were introduced at a spe-
on staffing in intensive care units and
cial presentation ceremony, followed
improved patient outcomes. Also
by a reception in their honor. MAJ(P)
receiving an award in the category of
Jaghab was accompanied by his wife,
Innovation in Patient Safety and
Delmy, and his children, Jasmine (9)
Quality on the national level were
and Danny (7). Also attending the cer-
Kaveh Shojania, MD and Robert
emony in support of MAJ(P) Jaghab
Wachter, MD, developers of WebM&M,
was CAPT Deborah McKay, Director of
the first internet-based patient safety
the Patient Safety Program and COL
resource and journal. The University
Eugene Miller from the Office of the
of Pittsburgh Medical Center-
Surgeon General. Representing the US
McKeesport was recognized for
Army Center for Health Promotion and
Innovation in Patient Safety and
Preventive Medicine, where MAJ(P)
Jaghab is currently Nutrition Staff
Officer, were COL Joann
Hollandsworth, Director of Health
Promotion and Wellness, and LTC
Teresa Hall, Health Systems
Coordinator of the Directorate of
Health Promotion and Wellness.
Congratulations to MAJ(P) Jaghab from
the entire DoD Patient Safety Program
for his significant contribution to
improving patient safety and for his
nationally recognized award. All
providers are encouraged to review
the MPEG Training Program on the
DoD Patient Safety Website at:
https://patientsafety.satx.disa.mil.
2

NEWS FROM THE
PATIENT SAFETY
CENTER
Feedback and Suggestions
• When critical laboratory values
Based on Your Reporting
JACHO SAFETY
GOAL
STRATEGIES
Implementation
Suggestions for New 2005
Recommendations
• When the provider isn’t notified
By: Mary Ann Davis, RN, BSN, MSA
Nurse Risk Manager, Patient Safety
Center
I mplementation of the JCAHO 2005
National Patient Safety Goals is
quickly approaching.The National
Patient Safety Goals were developed to
promote specific improvements in
patient safety.They continue to multi-
ply and/or become accreditation stan-
dards, as safety becomes an integral
part of patient care.The 2005 Patient
Safety Goals include five new goals
and three new requirements.The DoD
• When there is a repeat collec-
Patient Safety Center has reviewed
information received from our Military
Treatment Centers (MTFs), JCAHO and
relevant literature to supply sugges-
tions on how to meet these goals. In
addition to training and in-services, the
following ideas may help implement
the goals in your facility.
Goal #2, new requirement – measure,
assess and, if appropriate, take action
Goal # 3, new requirement –
to improve the timeliness of reporting,
and the timeliness of receipt by the
responsible licensed caregiver, of criti-
• When a blood specimen is inad-
cal test results and values.
equate and lab results are mis-
leading check the equipment
• When incorrect medication
• Are the manufacturers rec-
that was used:
ommendations being fol-
• Is there an established poli-
lowed;
cy on how to collect the
• Are there problems with the
blood or tissue;
equipment that should be
reported to the manufactur-
• Should the equipment be
er;
changed or modified?
are missed in the computer sys-
tem check the information that
• Is there a way to highlight
is provided within the system:
abnormal levels for easy
• Are abnormal levels listed in
viewing;
a conveniently accessible
area within the computer
• Should additional blood tests
system;
be given critical value levels
in the system?
of the abnormal blood results
look at how the information was
• Is there a list of laboratory
transmitted:
tests that are routinely
• Are the results reported via
reported;
email, phone or with a
• Who sends and receives the
paper report;
• How and when is the infor-
results;
mation given to the ordering
provider?
tion of a hemolyzed specimen
from the same patient clarify the
policy for reporting repeat test-
• Is the laboratory technician
ing:
required to report this
occurrence to his supervisor
or to the ordering physician?
identify and, at a minimum,
annually review a list of look-
alike/sound-alike drugs used
in your organization, and take
action to prevent errors
involving the interchange of
these drugs.
label leads to dispensing of
• Check the arrangement of
wrong medication:
• Rearrange the bins (not in
the medication bins;
3
alphabetic order or in order
of like-sounding medica-
• Affix “name alert “ stickers
tion);
to the areas where look alike
or sound alike medications
• Place additional label on
are stored;
newer medications to differ-
entiate them from estab-
• Review the physical layout
lished medications;
of medication bins; can addi-
tional space be allocated to
help with the handling and
• When different drug formula-
storage of the medications?
tions (e.g.,Amphotericin B) have
increased the likelihood of the
• Consider limiting the med-
wrong drug being given:
ication to one or two formu-
• Change the labels so they
lations;
are written with the brand
• Order by brand and generic
name;
• Encourage staff to use both
name;
• Place an alert in the comput-
the brand and generic name;
er indicating the need to use
the brand name with the
generic name when pre-
• When there is a computer error
scribing the medication.
related to a look-alike, sound-
• Mandate the complete name
alike medication:
• Install a maximum dose
for the medication selection;
Continued on page 4
JACHO WEBSITE
Anyone wishing to review the 2005
National Patient Safety Goals at their
source should access the JCAHO website:
www.jcaho.org, and click on “National
Patient Safety Goals & FAQs” under the
“Top Spots” heading. For both 2004
and 2005 you will find program specific
goals. To thoroughly understand each
goal, also review the links to: “Rationale
and Interpretive Guidelines” and “FAQs”,
which includes a complete list of new
look-alike/sound alike drugs.
NEWS FROM THE • Review the fall assessment
worksheet to ensure it
PATIENT SAFETY includes detailed instruc-
tions and easily understood,
CENTER
Patient Safety Links
Interesting Resources To Explore
Joint Commission on Accreditation of
Healthcare Organizations

• Check that documentation is

clearly written definitions; www.jcaho.org
Feedback and Suggestions complete and appropriate
Sentinel Event Alert: Issue 31, August 31,
2004

Based on Your Reporting providers are notified of any

Revised guidance to help prevent ker-
nicterus.
areas of concern. Sentinel Event Alert: Issue 32, October 6,
continued from page 3 2004
Preventing, and managing the impact of
Goal # 10, new goal for 2005 – anesthesia awareness.
warning to alert the user of
• Evaluate the first element of the
reduce the risk of surgical fires.
a possible medication error American Medical News
when inputting the order www.amednews.com

• Is there a paper drape in

fire triangle – the fuel: Vol. 47, No. 30

•
entry; “Senate Passes Patient Safety Bill”
Change the appearance of Report on latest Senate action on national

• What is the level of drape

use; system for collecting medical error data.
look-alike product names on
the computer screen by
• Select drape material with
Annals of Family Medicine
lint production; www.annfammed.org
using bold face, color or tall
July/August, 2004

•
man letters;
• Evaluate the second element of
the greatest fire protection. Two editorials and reports on four primary
Install computer alerts for care patient safety studies:

•
look-alike medication; “Preventing Errors in Clinical Practice: A

• Is oxygen necessary during

the fire triangle — oxygen use: Call for Self-Awareness”; “A String of
Construct the computer Mistakes: The Importance of Cascade
selection screens and dis- Analysis in Describing, Counting and

• Is the level of oxygen consis-

the procedure; Preventing Medical Errors”; “Event
pensing screens in a way
Reporting to a Primary Care Patient Safety
that will eliminate two simi- Reporting System: A Report From the ASIPS
tent with the patient’s
lar medications from appear- Collaborative”; “Patient Reports of
needs, can the level be low-
•
Preventable Problems and Harms in Primary
ing consecutively;
• Evaluate the third element of
ered to 30% from 100%? Health Care”.
List the brand and generic
name of the medication in VA National Center for Patient Safety
the fire triangle — the ignition www.patientsafety.gov
the computer system and for
• How close to the oxygen is
source: TIPS – official patient safety newsletter of
look-alike, sound-alike med- the Department of Veterans Affairs.
ications note the action of July/August, 2004 – “How to Make the Most

• Can the equipment be

the equipment?
the medication.
moved to another location
Goal # 9, new goal for 2005 - reduce
• Can the equipment be
when not in use;
the risk of patient harm resulting from
of Actions and Outcome Measures”— effec-
tive actions in response to RCAs and strate-
gies in building outcome measures; includes
a practical table of examples.
September/October, 2004 – “Ensuring
Correct Surgery and Invasive Procedures”.

• When there is a fall after a pro-

falls.
• When there is a chance of igni-
placed in standby mode? Premier Safety Share Institute
www.premierinc.com
cedure consider the feasibility of October, 2004
tion during a procedure, ensure “Patient fall rates drop 20% using innova-
using a transport team for
that saline is readily available in tive prevention strategies”: cites study
patient movement off the ward
• Is there active dialogue prior
the operating suite: reported in June, 2004 Joint Commission

• Review the data related to

for tests and procedures: Journal on Quality & Safety (Vol. 30, No.6)
entitled “Take a Second Glance”, describing
to and during the procedure Northwestern U. fall prevention program.
time of day, ward staffing, Includes links to two other fall prevention
between the operating sur-
level of provider for trans- resources:
geon and anesthesia staff re: Premier Safety Institute Fall Prevention
port, type of procedure,
the prevention of surgical Site; State Resources.
ward census and acuity of
• Are saline soaked gauzes or
fires?
• Use this information as a
patients; New England Journal of Medicine
www.nejm.org
sponges used to minimize Two related articles on interns’ work hours
guide to help with the and medical errors in Vol 351, Oct. 28, 2004,
leakage of oxygen if No. 18:
assessment and to help
uncuffed endotracheal tube “Effect of Reducing Interns’ Weekly Work

• Reassess the patient’s condi-

assemble the transport team;
• Is the oxygen used at lowest
is used? Hours on Sleep and Attentional Failures”
(pp. 1829-1837);
tion after a procedure or “Effect of Reducing Interns’ Work Hours on
concentration? Serious Medical Errors In Intensive Care
when there is a change in Units” (pp. 1838-1848).

• When there is a fall after the ini-

the patient’s physical status.

tial fall assessment is completed:

4
PATIENT system was launched at Wright-
Patterson. Initially, the system was cre-
ments; and, over-all, an increased facili-
ty-wide participation in the review

SAFETY IN ated with Powerbuilder software and

Sybase database. It was converted to a
process. The system has been enthusi-
astically approved in demonstrations

ACTION web-based application using ASP.NET

front-end and Oracle 9i database back-
to clinical gatherings. If the Air Force
Surgeon General’s Requirements
Experiences and end to meet security requirements. It
has the potential for wide area net-
Oversight and Capabilities Council
approves, it will soon be available to
Suggestions From the Field work access, but currently is config- all users of the Integrated Clinical
ured only for intranet access. Any net- DataBase (ICDB).
worked personal computer in the facil-
MEDICAL ity can serve as a records review plat-
form and access records review data.
RECORD Information security is ensured by
REVIEW MADE password access and privileging of BE AWARE WITH
users.
EASIER “PROJECT NEWS
Wright-Patterson Develops The MRRTS database contains a cen-
SHARE”
tralized set of questions.Virtually any
Own System patient care standard that can be
reviewed in the documentation of a
Call for Patient Safety

T
he medical record in today’s
health care facility is a vitally
clinical encounter can be entered into Newsletters
the database. Since its inception, over
important repository of data.
215 questions have been used by
Review of the medical record yields
insight into quality, compliance, cre-
Wright-Patterson to assess perform-
ance, with no less than 35 questions
T he fourth annual National Patient
Safety Awareness Week, sponsored
by the National Patient Safety
dentialing, individual and institutional
related to patient safety issues. Foundation, is scheduled for March 6-
progress. However, most healthcare
(Examples include: “Appropriate coun- 12, 2005.
facilities struggle with how to effi-
seling for discharge medications was
ciently, systematically review, extract
performed to include potential drug- In preparation for this national educa-
and apply medical records data in
drug and drug-food interactions”; tion and awareness building campaign
addressing patient safety and other
“Abnormal data collected by clinic aimed at improving patient safety at
issues.
staff and technicians is addressed dur- the local level, Patient Safety
ing patient’s visit”;“The patient’s Newsletter asks you to join Project
Wright-Patterson Medical Center devel-
assessment includes the identification News Share. We know that some
oped a medical records review system
of learning needs and barriers to learn- MTFs publish in-house patient safety
it believes is the most effective, user-
ing”.) The system makes aggressive use newsletters. If your MTF publishes a
friendly system available. The Medical
of standard reports, which are shared local patient safety newsletter please
Records Review Tracking System
with providers and clinical groups. In send a copy to the Newsletter
(MRRTS) was designed by an in-hospi-
the case of the Patient Safety Group, (poetgen@aol.com) so that we can
tal team: (LtCol. (Dr.) William Venanzi
data generated from MRRTS reports is share your efforts in the winter issue.
(Chair), Ms. Gail Elliott, Medical
used to develop priorities for root Include a brief note telling us how
Records Flight leader, and Mr.Tuan
cause and failure mode/effects analy- often you publish your newsletter, how
Tran, IT Support Contractor), charged
ses, to monitor the effects of interven- you circulate it, and how you think it
with establishing a consistent records
tions, identify trends and suggest contributes to your patient safety
review system to improve the existing
opportunities for improvement. Since efforts.
quality and scope of review and feed-
its inception, MRRTS has been expand-
back.The team focused on the devel-
ed to include in-patient and out-patient Together we can provide a timely
opment of a set of centrally controlled
records review, all treatment areas, response to Patient Safety Awareness
review parameters, including a core
physical therapy and death reviews. Week by sharing our individual com-
group of review questions, to docu-
ment the quality of the medical record munication tools, and working cooper-
Wright-Patterson believes the MERRTS atively to expand our awareness of
and the quality of medical care.
system offers multiple benefits: auto- successful patient safety efforts.
mated, standardized reports for a wide
In May 2000, after eighteen months of
variety of patient care standards; quali-
investigation, and with the hands-on
ty, user-friendly feedback to the entire
involvement of an information technol-
facility and specialized for depart-
ogy support contractor, the MRRTS

5
 INFECTION spotlighting actions to contain the
spread of contagious diseases like the
CONFERENCE CONTROL common cold, strep throat and
influenza is especially important,
CALENDAR MAKES given the national shortage of flu vac-
cine.

16TH NATIONAL FORUM ON

PATIENTS JCAHO is urging Americans to do
QUALITY IMPROVEMENT IN SAFER three easy things to fight infections:
Clean Your Hands. All healthcare
HEALTH CARE JCAHO Offers Easy providers should review the CDC
hand hygiene guidelines and encour-
December 12-15, 2005
Orlando, Florida Three-Step Campaign age renewed compliance.
Cover Your Mouth and Nose. And
www.ihi.org remember to wash your hands after.

4TH ANNUAL FORUM FOR

T he Joint Commission on
Accreditation of Healthcare
Organizations (JCAHO) has joined
Avoid Close Contact. If you are sick
with fever or symptoms of contagious
with a number of other national illness, you place others at risk by
IMPROVING CHILDREN’S
health associations to promote an putting yourself in their presence.
HEALTH CARE easy three-step campaign to help con- Stay home.
February 28-March 2, 2005 trol the spread of infections in health-
San Diego, California care settings and the community this According to Denise Cardo, MD, direc-
winter. JCAHO has focused on infec- tor, Division of Health Care Quality
www.ihi.org Promotion, CDC: “Preventing the
tion control in the past, issuing a
Sentinel Event Alert in January, 2003 spread of infection in healthcare set-
1ST ANNUAL INTERNATIONAL recommending compliance with the tings protects patients and saves
SUMMIT ON REDESIGNING Centers for Disease Control and lives….Good hand hygiene is espe-
Prevention (CDC) hand hygiene cially important”.
HOSPITAL CARE
guidelines. This winter, however,
June 8-10, 2005
San Diego, California
www.ihi.org

HEALTHCARE INFORMATION Patient

AND MANAGEMENT SYSTEMS
SOCIETY (HIMSS)
Co-sponsored by Office of Assistant
Secretary of Defense for Health Affairs
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
February 13-17, 2005 on the progress of the DoD Patient Safety Program.
Dallas, Texas
DoD Patient Safety Program
www.himss.org Office of the Assistant Secretary of Defense (Health Affairs)
TRICARE Management Activity
ACHE CONGRESS ON Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, Virginia 22041
703-681-0064
HEALTHCARE MANAGEMENT
March 14-17, 2005 Please forward comments and suggestions to the editor at:
Chicago, Illinois DoD Patient Safety Center
www.ache.org Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910
Phone: 301-295-8115 • Fax: 301-295-7217
7TH ANNUAL PATIENT SAFETY E-Mail: patientsafety@afip.osd.mil • Website:http://patientsafety.ha.osd.mil
CONGRESS E-Mail to editor: poetgen@aol.com

May 5-9, 2005 DIVISION DIRECTOR, PATIENT SAFETY PROGRAM: CAPT Deborah McKay
Orlando, Florida DIRECTOR, PATIENT SAFETY CENTER: Geoffrey Rake, M.D.
SERVICE REPRESENTATIVES:
www.npsf.org ARMY: LTC Steven Grimes
NAVY: Ms. Carmen Birk
AIR FORCE: Lt Col Beth Kohsin
PATIENT SAFETY BULLETIN EDITOR: Phyllis M. Oetgen, JD, MSW