The Department of Defense (DoD) Patient Safety Program (PSP) eBulletin delivers patient safety updates, news, useful tips and resources to help you deliver the highest quality of care to your patients. This month, learn about the history of Patient Safety Awareness Week and the events and activities happening this month, and meet PSP's new chief of patient safety.

Announcements and Reminders

• In March, the Military Health System's (MHS's) theme is Brain Injury Awareness Month. 
• In case you missed it, the new "Guidebook for Eliminating Wrong Site Surgery and Procedure Events" was released in February 2017. If you missed the introductory webinar, please log into the PSLC for the webinar archival. >>Request a copy of the Guidebook.
• Applications for the Agency for Healthcare Research and Quality's Click to closeTeamSTEPPSTeam Strategies and Tools to Enhance Performance and Patient Safety (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: Phase I Assessment: Facility determines organizational readiness; Phase II Planning, Training & Implementation: Facility “decides what to do” and “makes it happen;” and Phase III Sustainment: Facility spreads the improvements in teamwork performance, clinical processes and outcomes resulting from the TeamSTEPPS initiative.TeamSTEPPS Advanced Courses in 2017 are being accepted through March 21. These courses are available at no cost at regional training centers. >>Visit the AHRQ web site to learn more
• Patient Safety Awareness Week, National Doctor's Day, National Healthcare Decisions Day and Medical Lab Professionals Week are among other awareness celebrations that are coming up. Follow the PSP Facebook page for related content.
• The next eBulletin will be released on May 1.
• The 19th Annual National Patient Safety Foundation Patient Safety Congress is May 17-29, 2017. >>Learn more about the 19th Annual National Patient Safety Foundation Patient Safety Congress
• Do you have questions about the Continuing Education process? We can help! Email us.
• Do you have an update from your facility? Let us know via e-mail or Facebook.

Feature: The History of Patient Safety Awareness Week: A Q&A with Dr. Tejal Gandhi

The Department of Defense Patient Safety Program (DoD PSP) partners with other organizations in and outside of the DoD to foster a culture of sharing information and proven best practices. Through these strategic partnerships, the Military Health System (MHS) staff have the opportunity to advance their knowledge… Feature: The History of Patient Safety Awareness Week: A Q&A with Dr. Tejal Gandhi.

Patient Safety In Action: Patient Safety Awareness Week 2017

Patient Safety Awareness Week kicks off on March 12 and the Department of Defense Patient Safety Program (DoD PSP) has a variety of opportunities to recognize "United in Patient Safety." Patient Safety Awareness Week offers an opportunity to recognize the importance of quality care and patient safety… Patient Safety In Action: Patient Safety Awareness Week 2017.

Meet DoD PSP's New Chief of Patient Safety

The Department of Defense Patient Safety Program (DoD PSP) has recently expanded its leadership team with the addition of Dr. Daniel Ross. Dr. Ross has a background that includes a wide range of education and experiences including dentistry, oral surgery, emergency medicine, clinical professorships and… Meet DoD PSP's New Chief of Patient Safety.

DoD PSP Treasure Chest: March Edition

Welcome to the March edition of the DoD PSP Treasure Chest! 

Each issue, we share resources to help you execute your day-to-day patient safety activities easily and effectively. Please visit us often and get access to tools and information developed with… DoD PSP Treasure Chest: March Edition.

MHS Patient Safety Data Snapshot

The MHS Patient Safety Data Snapshot is a monthly compilation of two types of patient safety data:

1) Sentinel Event (SE) notifications submitted to the Patient Safety Analysis Center (PSAC)

2) Anonymous, voluntarily reported patient safety events via the web-based incident reporting system known as PSR

This publication provides an MHS enterprise-level snapshot of trends in SEs and PSR events so that providers and health care administrators can help identify areas for patient safety improvement in their facility and throughout the MHS

Visit the Patient Safety Learning Center (PSLC) to access the latest MHS Patient Safety Data Snapshot, available on the 15th of every month.

*Please visit the PSAC page of the PSLC to access and download this publication.

MHS Patient Safety Spotlight

The MHS Patient Safety Spotlight is a resource designed to highlight best practices and interesting initiatives that come from the field and are worthy of being shared across the enterprise. This resource features data-driven examples of improvement and case studies that tackle specific problems with specific solutions.

Visit the Patient Safety Learning Center (PSLC) to access the latest MHS Patient Safety Spotlight, available on the 15th of every month.

*Please visit the PSAC page of the PSLC to access and download this publication.

 
Upcoming Events

Patient Safety Learning Circles

In-person or Web-based forums focused on a specific topic.

TeamSTEPPS Webinar – Agency for Healthcare Research and Quality (AHRQ)

Please check our Calendar of Events for updates on this webinar.

Accreditation and Certification Webinars – The Joint Commission

Note: There are multiple opportunities to attend accreditation and certification webinars offered by The Joint Commission. >>Visit the Joint Commission web site to learn more about their webinars

The Right Care, Right Setting, and Right Time of Hospital Flow – Institute for Healthcare Improvement (IHI)

March 9, 2017 from 2 p.m. to 3 p.m. EST

Speakers:

• Frederick C. Ryckman, MD,  professor of surgery, senior vice president medical operations, Cincinnati Children's Hospital Medical Center (CCHMC)
• Uma R. Kotagal,  MBBS, MSc, executive lead community and population health, CCHMC
• Pat Rutherford, RN, MS, vice president, IHIAmy Feaster, vice president of information technology, Centura Health

>>Visit the IHI web site to learn more about this webinar

Patient Safety Awareness Week Events

Joint VA/DoD Webinar Series: PSP Session

March 15, 2017 from 12:30 p.m. to 2 p.m. EDT

Speakers:

• Naval Hospital Pensacola – "Hepatitis C Evaluation Prevention and Cure (H.E.P.C.) Program"
• Carl R Darnall Army Medical Center – "Optimizing Asthma Management"
• Naval Medical Center San Diego – "Oxytocin Protocol"

For more information, please go to the PSLC Calendar of Events.

The Voice of the Patient and the Public – National Patient Safety Foundation (NPSF)

March 15, 2017 from 2 p.m. to 3 p.m. EDT

Complimentary NPSF Professional Learning Series webcast in conjunction with Patient Safety Awareness Week and moderated by NPSF CEO and President Dr. Tejal Gandhi.

Speakers:

• Marshall Allen, Reporter, ProPublica
• Rosemary Gibson, senior advisor, The Hastings Center
• Martin J. Hatlie, JD, president & CEO, Project Patient Care

>>Visit the NPSF web site to learn more about this webinar

Joint VA/DoD Webinar Series: PSP Session

March 16, 2017 from 12:30 p.m. to 2 p.m. EDT

Speakers:

Naval Medical Center San Diego:

• "A Standardized Nurse Initiated Protocol to Improve Management of Severe Hypertension in Pregnancy"
• "Postpartum Hemorrhage Reduction Through Implementation of a PPH Treatment Bundle"
• "Operation PINC: Process Improvement for Non-delayed Contraception"

For more information, please go to the PSLC Calendar of Events.

Healthcare Resolution/Disclosure – ECRI Institute

March 23, 2017 from 1 p.m. to 2 p.m. EDT

Speakers:

• Lee Patrick, RN, BHA, MBA, CPHRM, HEM, CPASRM, patient safety analyst/consultant, ECRI Institute
• Barbara Moidel, MHS

For more information on registering for this webinar, please e-mail TQMC@ECRI.org or call (610) 825-6000, ext. 5800.

Better Care for Patients with Complex Needs – Institute for Healthcare Improvement (IHI)

March 23, 2017 from 2 p.m. to 3 p.m. EDT

Speakers:

• Kedar Mate, MD, chief innovation and education officer, IHI
• Jose Figueroa, MD, MPH, instructor of medicine, Harvard Medical School; associate physician, Brigham and Women's Hospital
• Marian Bihrle Johnson, MPH, director of innovation, IHI

>>Visit the IHI web site to learn more about this webinar

Implementation of Best Practices for Safer Insulin Pen Use: Stories from the Frontline – Institute for Safe Medication Practices (ISMP)*

March 28, 2017 from 1:30 p.m. to 3 p.m. EDT

A variety of insulin pen injectors, collectively called "pens," are currently available in the U.S., with more products and concentrations becoming readily available every year. A number of hospitals have been significantly concerned about the use of pen devices because of the potential for blood-borne pathogen transmission if the pen device would be accidentally used on more than one patient. Such inadvertent multi-patient use of pen devices has been widely publicized in the media, effecting thousands of patients as far back as 2009.

Join ISMP and expert faculty as they describe the challenges faced at their organizations to ensure the safety of insulin pen use, and the steps they each have taken to implement best practices to enhance the safety of insulin pen use. In addition, our speakers will describe a number of risk identification measures used to alert practitioners to the potential use of an insulin pen on more than one patient.

Speakers:

• Amy F. Rosenberg PharmD, BCPS, medication safety specialist, Shands at the University of Florida, Department of Pharmacy Services
• Melissa Carlson PharmD, BCPS, assistant director of clinical services and medication safety officer, University of Minnesota Medical Center

Moderator:

• Michael Cohen, RPh, MS, ScD (hon), DPS (hon), FASHP, president, ISMP, Horsham, Pa.

This webinar is approved for 1.5 hours of Pharmacy Continuing Education and 1.0 hour of Nursing Continuing Education.

>>Visit the registration web site to learn more about this webinar

Certified Professional in Patient Safety Review – National Patient Safety Foundation (NPSF)**

March 31, 2017 from 10 a.m. to 5 p.m. EDT

Live webinar for experienced patient safety professionals who plan to take the Certified Professional in Patient Safety (CPPS) examination, to help prepare for the exam.

Participation in this course will provide attendees with the opportunity to:

• Review in depth the five patient safety domains, following the exam content outline
• Discuss patient safety scenario examples similar to actual exam questions
• Assess their own level of preparedness for the exam and address additional areas for self-study

Featured Faculty:

• Mark Jarrett, MD, MBA, CPPS, senior vice president & chief quality officer, associate chief medical officer, Northwell Health; Professor of Medicine, Hofstra – Northwell Health School of Medicine
• Judy Milne, MSN, RN, CPHQ, CPPS, patient safety officer, Duke University Hospital

Moderator:

• John B. Hertig, PharmD, MS, CPPS, associate director, Purdue University College of Pharmacy Center for Medication Safety Advancement

>>Visit the NPSF web site to learn more about this webinar

Patient Safety Workshops

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

On-Demand eLearning: Patient Safety Reporting System v1.01 eLearning Course

This course introduces basic navigation and functionality features of the PSR system and the roles of system users, such as event reporters, event handlers and investigators. The course can be accessed through MHS Learn.

Register now

On-Demand eLearning: Patient Safety Reporting: Intermediate Course*

Targeted to Patient Safety Managers and other military treatment facility (MTF) staff already familiar with basic functionalities of the Patient Safety Reporting System, this course is designed to help learners hone the decision-making skills needed to effectively manage patient safety event data in PSR, as part of the ongoing effort to eliminate preventable harm at MTFs.

Register now

On-Demand eLearning: Root Cause Analysis*

This self-paced module outlines the DoD Patient Safety Program's suggested practices for conducting a root cause analysis, from the initial reporting of a patient safety event through the formation of the RCA Team to the identification of contributing factors and root causes and the recommendation of corrective actions.

Register now

* Denotes that activity is eligible for Continuing Education (CE) credit. All CE credits are managed by the Postgraduate Institute for Medicine (PIM).

**Did you know? As an NPSF Stand Up for Patient Safety member, DoD PSP receives complimentary access to webinars as a benefit of program membership. Check with your facility POC to obtain the member coupon code.