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September/October 2018 eBulletin

The Department of Defense Patient Safety Program eBulletin delivers patient safety updates, news, useful tips and resources to help you deliver the highest quality of care to your patients. This month, read how transparency and health literacy effects patient safety, learn how daily huddles accompanied by whiteboards is improving connectedness across the Air Force, and get the latest news about a new resource for the dental patient safety community.

Announcements and Reminders

  • In September, the Military Health System’s theme is Suicide Prevention. Learn more about this theme>> 
  • In collaboration with the DoD Patient Safety Program, the Dental Patient Safety Integrated Product Team is releasing “A Guidebook for the Identification and Reporting of Dental Patient Safety Events” for the Military Health System dental community in fall 2018. The guidebook is a Tri-Service approach to clarify definitions and reporting requirements for patient safety events and sentinel events in MHS dental facilities. The DoD PSP will host learning events (webinars) for the dental patient safety community to introduce the guidebook and answer questions. Stay tuned for upcoming announcements on our calendar of events and via e-mail
  • Do you have questions about the DHA transition? Stay tuned for details on the new Defense Healthy Agency Procedural Manual being released on or around Oct. 1. This new manual will contain changes for all domains aligning under Clinical Quality Management including Patient Safety, Healthcare Risk Management, Credentialing and Privileging, Accreditation and Compliance, Clinical Measurement, and Clinical Quality Management. A learning series will be presented in October to provide an opportunity for all audiences to learn about the updates for their respective domains. Look for details in future e-mails, Learning Updates and on our calendar of events
  • Empower patients to properly care for themselves after discharge. The Agency for Healthcare Research and Quality has released an updated version of the “Taking Care of Myself: A Guide for When I Leave the Hospital.” Download or request copies here
  • The next eBulletin will publish in November 2018.
  • Do you have questions about the Continuing Education process? We can help! E-mail us.
  • Do you have an update from your facility? We’re always looking for good news stories and would love to hear from you! If you’d like to share an update, please contact us via e-mail or Facebook and one of our team members will contact you.
          

Feature: Improving Patient Safety by Improving Health Literacy, Transparency 

The Military Health System’s sharing of quality, patient safety and access information online empowers patients to ask questions and improve their health literacy. Feature: Improving Patient Safety by Improving Health Literacy, Transparency. 

Patient Safety in Action: Huddles around Whiteboards Help Airmen See the Big Picture

Air Force military treatment facilities use visual management boards to improve teamwork and communication across frontline staff and leadership. Patient Safety in Action: Huddles around Whiteboards Help Airmen See the Big Picture

HRO Corner: DoD PSP Collaborates with MHS Community to Standardize Dental Patient Safety

The Military Health System’s first-ever dental guidebook supports frontline staff, standardization of dental patient safety across the organization. HRO Corner: DoD PSP COllaborates with MHS Community to Standardize Dental Patient Safety

 

DoD PSP Treasure Chest: September/October Edition

DoD Patient Safety Program Treasure Chest

Welcome to the September/October 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 for our committed MHS patient safety champions!  

Read more. 

MHS Patient Safety Data Snapshot

An image of a camera on a blue circle
The MHS Patient Safety Data Snapshot is a monthly compilation of two types of patient safety data: 

1) Sentinel Event notifications submitted to the Patient Safety Analysis Center; and

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

This publication provides an MHS enterprise-level snapshot of trends in SEs and JPSR 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* to access the latest MHS Patient Safety Data Snapshot, available on the 15th of every month.

*Please visit the Patient Safety Analysis Center page to access and download this publication.

Upcoming Events

Click on the image on the right to view/print a list of all upcoming patient safety activities.
 
Patient Safety Learning Circles
 

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

 
TeamSTEPPSTeam 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® Webinar – Agency for Healthcare Research and Quality (AHA)

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

The Joint Commission

There are multiple opportunities to attend accreditation and certification webinars offered by The Joint Commission.

Learn more about these opportunities >>

 

 


The How and Why of Deprescribing – Institute for Healthcare Improvement (IHI) 

Sep 13, 2018 from 2-3 p.m. EDT

Patient Safety Learning Opportunity 
There’s much talk and publicity about weaning people off drugs, or what is referred to as “deprescribing,” a process that entails taking patients off some of their medications or tapering down the dosages. A growing number of healthcare organizations are working on how to safely implement deprescribing. At Ascension, one hospital is focusing on deprescribing (or, whenever possible, not introducing) opioids and sedatives among a targeted group of patients; three other hospitals are zeroed in on deprescribing proton pump inhibitors for gastrointestinal problems because of potential harm caused by long-term use. Listen in as the panelists share what they’ve learned about deprescribing initiatives.
Speakers:
  • Nicole Brandt, PharmD, MBA, BCGP, BCPP, FASCP, executive director, Peter Lamy Center on Drug Therapy and Aging; professor, University of Maryland School of Pharmacy  
  • Florian Daragjati, PharmD, BCPS, director, Ascension Center of Excellence for Antimicrobial Stewardship and Infection Prevention 
  • Lynn Deguzman, PharmD, BCGP, regional clinical operations manager, Kaiser Permanente
  • Leslie J. Pelton, MPA, director, IHI
  • Leanne Phillips, PharmD, BCPS, clinical pharmacy coordinator, St. Vincent’s East, Ascension

Learn more about this opportunity >>

 


Working Together to Address Global Drug Safety Issues with Packaging and Labeling – Institute for Safe Medication Practices (ISMP)

Sep. 26, 2018 from 11 a.m. - 12 p.m. EDT

Patient Safety Learning Opportunity

Many of the product container labeling and packaging issues are common across the world. To achieve a reduction of overall harm related to medication errors, industry and regulator response at the global level is desired. Also, in many countries and regions throughout the world, domestic drug manufacturing does not exist, so drugs are commonly imported, often with features that can result in safety issues. Join to hear an update on successful packaging and labeling changes that have been undertaken in some countries to reduce the risk of errors. Highlights from a recent international summit on drug labeling and packaging held by global regulators and the International Medication Safety Network will be described.

Speaker:
  • Michael Cohen, RPh, MS, ScD, DPS, FASHP, president, ISMP

Learn more about this opportunity >>


Health System Expansions: Anticipating What Could Go Wrong to Ensure Things Go Right – Institute for Healthcare Improvement (IHI)

Sep. 27, 2018 from 2-3 p.m. EDT

Healthcare systems in the U.S. are expanding in size and services by way of mergers, acquisitions, and affiliations. Evidence from such transitions and change has revealed that when clinicians are asked to practice in new settings, often with new leaders, infrastructure and patient populations, and without adequate orientation and planning, patients may be at increased risk of harm. Panelists will discuss their recent analysis of patient safety risks due to system expansion and a patient safety toolkit they’ve developed to support the planning that’s necessary ahead of time among merging institutions. 

Speakers:
  • Susan Haas, MD, MSc, obstetrician-gynecologist and co-PI, Ariadne Labs
  • Luke Sato, MD, chief medical officer and senior vice president, CRICO, Risk Management Foundation of the Harvard Medical Institutions

DoD patient safety champions can attend this webcast for free by contacting their service lead for an access code to apply at registration.

Learn more about this opportunity >>


NEW Dental Guidebook Coming!

In collaboration with the DoD Patient Safety Program, the Dental Patient Safety Integrated Product Team is releasing “A Guidebook for the Identification and Reporting of Dental Patient Safety Events” for the Military Health System dental community in fall 2018. The guidebook is a Tri-Service approach to clarify definitions and reporting requirements for patient safety events and sentinel events in MHS dental facilities. The DoD PSP will host learning events (webinars) for the dental patient safety community to introduce the guidebook and answer questions. Stay tuned for upcoming announcements on our calendar of events and via e-mail.



Have questions about the DHA transition?

Do you have questions about the DHA transition? Stay tuned for details on the new Defense Healthy Agency Procedural Manual being released on or around Oct. 1. This new manual will contain changes for all domains aligning under Clinical Quality Management including Patient Safety, Healthcare Risk Management, Credentialing and Privileging, Accreditation and Compliance, Clinical Measurement, and Clinical Quality Management. A learning series will be presented in October to provide an opportunity for all audiences to learn about the updates for their respective domains. Look for details in future e-mails, Learning Updates and on our calendar of events



 

 
 

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