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DODs Patient Safety Program works to eliminate preventable harm

Picture of a vital sign machine Observer-controller/trainers at the Mayo Clinic Multidisciplinary Simulation Center in Rochester, Minnesota, monitor the vital signs of a simulated patient at the 399th Combat Support Hospital, 804th Medical Brigade, 3d Medical Command (Deployment Support) out of Fort Devens, Massachusetts. The exercise was to practice Team Strategies and Tools to Enhance Performance and Patient Safety, or TeamSTEPPS (Photo by: Army Staff Sgt. Andrea Merritt).

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The goal of the Department of Defense's Patient Safety Program technological programs and systems is to — eliminate preventable patient harm.

Patient safety which is being highlighted during Patient Safety Awareness Week 2021, is the primary focus of the PSP. The program is designed to engage, educate, and equip patient care teams to create and set into motion evidence-based safety practices across the Military Health System.

The Joint Patient Safety Reporting (JPSR) system is a major part of the PSP. JPSR is a web-based application to standardize the capture of a wide range of patient safety concerns, from unsafe conditions through adverse harm events, including “good catches” across MHS military medical treatment facilities (MTFs) and the Department of Veterans Affairs. It is a critical tool that provides real-time data for local MTF leadership to track and trend data for process improvement and harm prevention, in contrast to other data sources with lag times from weeks to months.

Similar federal reporting systems exist, including the Centers for Disease Control and Prevention/Food and Drug Administration's Vaccine Adverse Events Reporting System (VAERS) and FDA's MedWatch adverse event reporting system. All are voluntary reporting, but key to catching a range of issues, analyzing data, and alerting relevant medical facilities around the world.

"JPSR captures, allows for secure investigations, and tracks patient safety events that may result in alerts which can be quickly disseminated to MHS health care providers," said Brian Anderson, Health Information Technology Systems lead and functional manager for JPSR. Self-reporting of potential adverse events is one of the key components in the MHS’s effort to achieve high reliability, continuously improve, and provide the safest patient care possible.

"Since the JPSR program was implemented for DOD in 2011, we have made many improvements as our health care system has evolved," said Anderson. "We have added many new medications, vaccines, new electronic health record choices and virtual health parameters. We now have nearly 18,000 registered account users between DOD and the VA. The near real-time data source is readily available for leadership, in contrast to other quality measures that have long lag times."

The PSP's Patient Safety Analysis Center analyzes the JPSR reported data to provide cumulative reports and feedback to MTFs. The analyses are also used to strengthen tools and processes to assist the MTFs and overall system to ensure safe practices.

"We have had a steady climb of JPSR reporting -- more event reporting each year increases transparency and learning from events, and processes continue to improve through the capture of near misses and unsafe conditions," Anderson said.

In the past four years, the JPSR system has expanded to include the U.S. Transportation Command Patient Movement System and U.S. Central Command deployed medical facilities as key partners, along with the VA system and the Joint Trauma System to provide integrated reporting. The implementation of the new electronic health record MHS GENESIS system, expected to be completed in 2023, also will be closely monitored via JPSR.

Another example of a key PSP tool is the Team Strategies and Tools to Enhance Performance and Patient Safety system, or TeamSTEPPS, an evidence-based framework of skills for improving patient safety through a comprehensive suite of ready-to-use materials, tools, and training materials. The framework is designed to optimize team performance across the health care delivery system.

At the center of the 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 paradigm are the patient, family, and core team, who receive the benefits of effective teams, ensuring effective communication for every patient, every time.

"Through engaged leader, vigilant practice, ongoing training and coaching, the teamwork system is an integral component of our culture," said Heidi King, DHA chief of the Patient Safety Program for Medical Affairs. "We use medical simulation in most TeamSTEPPS Train the Trainer classes. Simulation allows practice of the strategies and tools as a means to change strongly ingrained patterns of behavior in a low-threat environment. Practicing health care as a team is derived from military operations. Both learning from reported patient safety events and deliberate communication and teamwork enhance a culture of safety for Ready Reliable Care."

Health care professionals can learn more about the Patient Safety Program and its wealth of resources — including toolkits and guides — at the Patient Safety Program Toolkits & Guides | Health.mil.

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