| Patient Safety Reporting (PSR) system - Full Deployment Authorized It is up to all of us in the MHS to do all we can to provide our patients with a safe and positive experience. We can do this by continuing to cultivate a culture of teamwork and learning more about the ways we can enhance patient safety. The Patient Safety Reporting System (PSR) is a web-based tool that enables enterprise-wide reporting of both medication and non-medication-related patient safety events, including near misses. This anonymous and easy-to-use tool helps foster conversations on how to improve care through data analysis and enhanced data collection. Piloted in nine Military Treatment Facilities (MTFs) beginning March 2010, PSR Full Deployment was authorized in September 2010 per the provisions of TMA CAE's Acquisition Decision Memorandum (ADM) and with the endorsement of Acquisition Integrated Product Team (AIPT). Who uses PSR?
All MTF staff with a CAC card will use the PSR to report all types of events, from potential adverse events and near misses to Sentinel events. When reporting an event, PSR users have the option of reporting anonymously or including their name with the report. Those who include their name receive confirmation of the report and feedback. Patient Safety Managers and the Event Handler (or reviewer) whom they select can use PSR to manage and conduct an investigation after an event. Each data field within PSR provides an intuitive structure that guides event reporting and investigation. PSR helps with reporting events more easily, facilitates standardization of data and ensures completeness of reports. Now in full deployment, PSR will capture an unprecedented level of detail and richness of data in which facilities, Services and the MHS can track, trend and take action. Key Features
Causal and Contributing Factors list: provides the ability to identify the circumstances or factors that influenced the occurrence or risk of a patient safety event. These factors will help us understand how and why an event occurred to implement direct and effective corrective actions that will protect future patients. AHRQ Harm Scale: aligns with emerging U.S. and International Standards (AHRQ Common Formats). This scale allows patient-care teams to measure an event’s impact on a patient’s functional ability, including quality of life. The scale points are in order of degree of permanence and severity of impact from death to no harm. PSR also includes the categories “near miss” and “unsafe condition,” which are additions to the AHRQ harm scale. Why should we report events with PSR? Through event reporting we can identify threats to patient safety and seize opportunities for improvement. The correlation between an increase in patient safety reporting and decrease in harm events is substantial and compelling -- organizations that report events are safer systems. Patient safety is a shared responsibility that hinges on communication and collaboration. As we move from a blame-oriented environment to one that thrives on learning from events and near-misses, you can help us capture information, identify ways to improve safety and most importantly, provide the best care possible to our patients. For more information, contact your Service POC:
Army: jorge.carrillo@amedd.army.mil
Navy: carmen.birk@med.navy.mil
Air Force: beverly.thornberg@lackland.af.mil
Or
Visit the DoD PSP website  Sharing Stories…
A Ripple Effect of Impact Why is it important to share impact stories? It seems obvious, but so often we get bogged down in our day-to-day and forget to do it. Sharing stories about successful efforts and their impact is crucial in our field. Being reminded that others are in the same boat helps us to remember that we’re not alone, that others truly understand what we’re dealing with on a daily basis. Seeing how others deal with similar situations is an inspiration; and ultimately understanding others solutions becomes a tool we can use and apply in our own facilities. The two September Learning Action Network (LAN) webinars focused on sharing stories of impact across all Services. The first LAN featured Lt. Col Valerie Gail McDavid a dentist assigned to USA DENTAC Ft. Bragg. She explained what success stories are and why they are important. She described examples from Ft. Bragg and explained the concepts behind Kilpatrick’s 4 Levels of Program Evaluation and Diffusion of Innovations. Dr. McDavid described how to create highly effective success stores and what kinds of things make effective success stories. She discussed where the raw material comes from, where and when should we share these stories and what we should do with them. The second LAN featured representatives from each Service: Army: COL Robert M. Rush, Chief of Surgery of Madigan Army Medical Center; Navy: CDR Robert D. Jackson, Head, Department of Anesthesia of Naval Hospital Jacksonville and HMC Brian W. May, Operating Room of Naval Hospital Jacksonville; Air Force: Mr. Richard D. Browning, Director of Quality, Risk Management, Patient Safety and Patient Advocate of Beale Air Force Base They each shared successful patient safety experiences at their facilities. In sharing these stories each Service representative covered the issue, the solution and the impact. Army: Col. Rush shared how, after a particularly difficult winter at the Madigan Army Medical Center, the facility hit a breaking point. The facility had started to socialize the idea of TeamSTEPPS earlier in 2008, but as fall turned into winter, true implementation began. Initial training sessions were conducted, and leadership at the facility audited and surveyed the facility – and briefed the results, stressing that the new processes would be enforced. After implementing practices including surgical clinic initial visits, pre-op surgical services visits, team briefs and debriefs and check-backs, the leadership then conducted another audit. Teams continued to incorporate new practices such as daily noon meetings and daily specific team meetings. While the facility still has areas for improvement, Madigan has portrayed proven success – with an increase of “good catches” that prevented patient harm, an increase of forms completed, matching of preference card and case cart, and functional and operational instruments and equipment. Navy: The representatives, CDR Robert D. Jackson and HMC Brian W. May, from Naval Hospital Jacksonville shared several stories as well as a one-page template for highlighting the outcomes and impact of their efforts. For example, the hospital identified a need to reduce equipment loss to improve hospital cost control.  To accomplish this goal, staff sought to streamline the equipment disposal process by applying TeamSTEPPS®. The staff flowcharted the process, created a checklist, conducted team briefs and debriefs, made forms available online, streamlined handling of replacing equipment and assessed and planned solutions using the SOAR methodology (Strengths, Opportunities, Aspirations, Results.) As a result, the facility saw a 74% reduction in equipment losses. Air Force: Richard D. Browning discussed how the 9th Medical Group of Beale Air Force Base engaged their patients to become true members of the medical team. The team schedules a 20 minute time slot at individual Commanders calls and spouse organizations to educate and engage patients to improve patient experiences and outcomes. Topics discussed include clinic capabilities and challenges, over-utilizing the system with inappropriate appointments, patient and staff interaction / behavior and becoming an active member in your own medical care. The group also developed a brochure titled, “Everything You Need to Know about the 9th Medical Group (But Were Afraid to Ask).” This brochure gives high level information about the Medical group and includes answers to Frequently Asked Questions. Our field is moving towards a Patient Centered Medical Home (PCMH) model, a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. The example set by Beale Air Force Base can help lead the rest of us in this direction. The Patient Safety Program encourages you to share your impact stories. We will soon have updated impact story templates available for download and submission on the DoD Patient Safety Learning Center under the Culture of Safety section. We will notify you when these become available. In the meantime, if you have questions or would like to email your story, please send it to pspinfo@tma.osd.mil. Every day, you are saving patients’ lives. By keeping them safe and making patients the center of your care teams, you are giving our warriors the care they deserve. If you would like to attend the next LAN, register here. |