THIS ISSUE PSC EXPLAINS OUTCOME MEASURES

P AFETY
ATIENT
SPRING 2005

Page 2 Patient Safety Culture Survey

Update

S
Page 3 PSC Safety Alerts
Page 5 Medication Safety at NH Rota
Page 6 New AHRQ Website

SPRING 2005 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

Aeromedical Evacuation personnel, following Medical Director's signal, off load OIF casualties from AMBUS to awaiting C-130 for
transport in Iraq.

Patient Movement System Tracks Patient Safety

MTFs Can Help By Reporting Events ogy and training which enhance our ability ations. The medical professionals in all of
to meet the challenge of transporting our services are working hard to ensure
patients. Originally established as the every soldier has a chance to come home.

D
id you know that the Patient Move-
ment System was responsible for
over 28,000 patient movements in
calendar year 2004? And 4500 of those were
battle injured casualties from Operation
ENDURING FREEDOM and IRAQI
FREEDOM?
Times have changed since the Vietnam
War. We have learned a great deal about
moving large numbers of casualties and
there have been many advances in technol-
Aeromedical Evacuation (AE) Patient Safe-
ty Program, over the past two years the
program has been expanded and restruc-
tured under a unified Command to include
all transportation modes and providers of
patient movement, from patient prepara-
tion to receiving. Now called the Patient
Movement Safety Program, the network is
extremely complex, involving decision-
making from remote locations, multiple
handoffs, and often different Service affili-
One recent innovation of special
import is the comprehensive Patient Safety
Program for Patient Movement. The inte-
gration of all aspects of patient movement
under one command has made the collec-
tion and sharing of patient safety informa-
tion related to patient transport easier to
manage. Directed by USTRANSPORTA-
TION Command at Scott AFB in Illinois,
the program collects data on transport
Continued on Page 2
Patient Movement System
Continued from Page 1
patient safety events and near misses from
around the world. The Program is a web
based data collection process that uses the
DoD Form 2852 — the Aeromedical Evacu-
ation Event/Near Miss Report. The DD 2852
is available on the DoD forms page. The web
based collection tool is called the Patient
Movement Quality Tool (PMQ) and is locat-
ed at https://private.amc.af.mil/pmq/.
Lt Col Lisa DeDecker, the patient safety
program director, is very interested in
obtaining feedback on any patients you have
received through the Patient Movement sys-
tem. Most have been transported via the tra-
ditional Aeromedical Evacuation (AE) sys-
tem and some by commercial air ambu-
lances. Although events occurring during the
transport process are routinely reported, a
formal reporting system has not been estab-
lished between the receiving facilities and the
patient movement patient safety program.
MTFs are now being asked to help bridge
this gap. Of particular interest are events
experienced by patients after transport that
DoD 2005 Patient Safety Culture Survey
Fall 2005 Rollout Planned
U
ntil recently, limited tools to assess
patient safety culture have been avail-
able to DoD. However, plans for the
deployment of the Department of Defense
(DoD) 2005 Patient Safety Culture Survey are
underway. In 2002, DoD initiated dialogue
with the Agency for Healthcare Research and
Quality (AHRQ), which funded the develop-
ment of a patient safety culture survey, to
assess the culture of patient safety within Mil-
itary Health System (MHS) facilities.
The DoD Patient Safety Culture Survey
will be a web-based survey designed to assess
staff opinions about issues related to patient
safety, medical errors, and error reporting. All
125,000 staff working in CONUS and
OCONUS Army, Navy, and Air Force Military
Treatment Facilities (MTFs) and dental treat-
ment facilities will be asked to complete this
survey. Rollout is tentatively scheduled for fall
2005. Current plans are to use the survey for
one cycle and then evaluate for any future
implementations.
The survey assesses the following aspects
of patient safety in Military Health System
Contingency Aeromedical Staging personnel prepare to receive casualties in Iraq.
are possibly related to transport. Examples of
such events are deep vein thrombosis or pul-
monary embolism, pressure decubitus, or
infections. Normally events or near misses
that are identified within 24 hours of trans-
port could potentially be attributed to the
transport process.
If you have any information or feedback,
please contact Lt Col DeDecker at DSN 779-
5205 or commercial 618-229-5205. You can also
email her at lisa.dedecker@hqtranscom.mil.
LEADERSHIP ENCOURAGES SURVEY SUPPORT
“The DoD Patient Safety Program is
dedicated to improving patient safe-
ty in all military health care settings
through evaluating processes and
systems of health care delivery in
military treatment facilities.
This survey will help the DoD’s Mili-
tary Health System realize our mis-
sion of improving patient safety by
enabling open promotion and dis-
cussion regarding the identification
of safety issues specific to each
unique environment in our system.”
— David Tornberg, MD, MPH
Chief Medical Officer
TRICARE Management Activity
November 2004
facilities:

Overall perceptions of safety

Frequency of reporting events

Supervisor and manager expectations
and actions promoting safety
2 SPRING 2005 PATIENT SAFETY
MTFs Receiving Most Patients From
Patient Movement System in 2004
Brooke AMC, Ft Sam Houston, TX
Darnall ACH, Fort Hood, TX
Eisenhower AMC, Ft. Gordon, GA
Ft Drum USAHC, NY
Ireland ACH, Fort Knox, KY
Madigan AMC, Tacoma, WA
Nat Nav Med Center, Bethesda, MD
Nav Hosp CP Pendleton, CA
Walter Reed AMC, Washington, D.C.
Womack AMC, Ft. Bragg, NC

Organizational learning/continuous
improvement

Teamwork within and across
departments

Communication issues

Nonpunitive culture in response to error

Staffing issues

Issues related to handoffs and transitions
Group survey results will be reported at
the facility and Service levels, as well as the
MHS overall. Strengths and potential areas for
improvement will be identified. The results
will help the DoD assess the status of patient
safety and improvement efforts within MHS
facilities, raise staff awareness about patient
safety, and meet requirements of the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO).
The success of the survey depends on the
total participation of MHS staff. Further
details will be forthcoming in the Summer
Newsletter. Please contact CAPT Deborah
McKay, Division Director of the Patient Safety
Program in the Office of the Assistant Secre-
tary of Defense for Health Affairs, at 703-681-
0064 or deborah.mckay@tma.osd.mil, with
any questions or comments.
 NEWS FROM THE PATIENT SAFETY CENTER
Feedback and Suggestions Based on Your Reporting
Outcome
Measures
What Are They And Why Are
They Important?
Mary Ann Davis, RN, BSN, MSA
Nurse Risk Manager, Patient Safety Center
Safety personnel expend a great deal of
time and energy completing a Root Cause
Analysis (RCA) and identifying detailed
action plans to rectify the causes of prob-
lems. However, how do you know if the
actions you implement are effective? Once
actions are put into practice, you should be
measuring their effectiveness through the
use of outcome measures. The Patient Safety
Center (PSC) often receives RCAs listing sev-
eral actions, but frequently receives RCAs
that identify actions as outcome measures or
that lack outcome measures altogether.
Outcome measures are necessary to
ensure that actions adopted to eliminate or
reduce the recurrence of an event actually do
just that. In order to measure the effective-
ness of an action there needs to be a per-
formance threshold set for the performance
goal, and a numerator and denominator to
determine if the action accomplishes its goal.
If the event is a JCAHO reportable sentinel
event, the JCAHO follow-up report should
detail how the actions were implemented,
how these actions were monitored and how
safe practices were adopted and carried out.
Most importantly, the report should deter-
mine the effectiveness of the action using
data.

To conform to JCAHO requirements,
the follow-up report should assess:

The implementation of system and
process improvements identified in
the action plan.

The organization’s response to data
collected to measure the effective-
ness of the actions.

The means by which the organiza-
tion will continue to assess the
effectiveness of those efforts.1

Here are areas we suggest you review as
you develop your outcome measures:

Determine the sample size, the
sample composition, the method
for collecting the data and how the
data will be analyzed.


Determine the timelines used and
the target outcome range.
training test will be given and 90% correct
will be the passing grade, or there will be a

Determine the frequency of the
data collection and the accessibility
compulsory repeat training.

Outcome Measure: 100% of staff will
of the data.

If possible, utilize data that is
receive a passing grade within 90 days of ini-
tial training. The numerator is the number
already available at your facility to
of staff that passed the post training test over
help with measurements.
the denominator: all clinical and profession-

If possible, use previously devel-
al staff within the facility. Goal is 100% com-
oped and validated measurement
pliance.
tools.

Outcome Measure: Audit all professional

Utilize staff that have an interest in
and clinical support staff ’s education folders
the outcome or have specialized
to verify training within 45 days. 100 % com-
training in a related field.
pliance is the goal.

Protect your patients’ rights to pri-

Outcome Measure: Following the com-
vacy and safety.
pletion of training by all staff, randomly

Keep it simple.
audit 30 charts monthly for 3 months to
Outcome measures should be quantifi- check compliance with the new procedure.
able or measurable. For example, if medical 100% sample compliance is the goal, or the
record or test results are going to be audited, audit will continue for another 3 month
JCAHO recommends a 100% audit for less period with retraining where identified defi-
than 30 records or a 5% audit for more than ciencies are noted.
30 records. JCAHO also recommends a com- Action: Implement a new policy and
pliance goal of 90% for most types of action revised procedure for testing lab specimens.
and 100% for a serious event. JCAHO
Outcome Measure: Randomly audit 5%
requires that implemented actions show an of lab records weekly for 3 months. Numer-
improvement in outcomes. ator is the number of errors over the denom-
Here are some examples of outcome inator: total number of tests audited. 100%
measures derived from identified actions. sample compliance is the goal.
You should keep in mind that there can be
Outcome Measure: Using the tracer
more than one outcome measure per action. method, (following a staff member or
Action: Train all of the professional and patient thru a process) randomly pick 5 indi-
clinical staff on a new procedure related to viduals per week for 2 months to identify
patient identification within 30 days. A post Continued on Page 4
DEPARTMENT OF DEFENSE (DoD) PATIENT SAFETY ALERTS
A Reminder from the Patient Safety Center
Over the last year and a half the DoD Patient Safety Center (PSC) has issued
four Patient Safety Alerts. Based on actual events, the alerts recommend specific
actions to be taken to prevent recurrence of these potentially avoidable events.
Recently, for example, the PSC released an alert concerning medical gases based
on a mix-up between O2 and CO2 tanks with tragic results for a newborn infant.
This alert covers facility risk assessment and recommended actions for their con-
sideration. Safety Alerts are available on the DoD Patient Safety Web Site (DoD
Patient Safety - DoD Patient Safety Center - Safety Alerts)
The four alerts to date include:

Issue 1, 21 Nov 2003 – Concentrated Electrolyte Solutions and High Dose
Epinephrine

Issue 2, 12 Feb 2004 – Similar Packaging and Labeling of Insulin and
Tuberculin Syringes May Lead to Errors

Issue 3, 3 Feb 2005 – A Change in Manufacturers Can Lead to Errors
with Acetaminophen and Ibuprofen Liquid

Issue 4, 22 Mar 2005 – Medical Gas Sentinel Event
PATIENT SAFETY SPRING 2005 3
Patient Safety Center
Continued from Page 3
compliance of the procedure. 100 % compli-
ance is the goal.
Action: Implement a time out procedure
on all dental extractions as a final identifica-
tion verification.

Outcome Measure: Audit all dental
records with extractions for one month then
randomly audit 5% once a month for 3
months. Numerator is the number of time
outs documented over the denominator:
extraction procedures noted in the dental
records. 100% compliance is the goal.
After the action plans are implemented
and a review of outcome measures show that
your specified goals have been accomplished,
you should monitor the process on an ongo-
ing basis, (using tracers or quarterly record
audits, for example), to ensure that the
improvements in the process or procedure
are being maintained.
The Department of Veterans Affair is
another source of information on actions
and outcome measures. Their website offers
a table of examples.2
1
Sentinel Event Policy and Procedures Revised:
July, 2002 http://www.jcaho.org/accredit-
ed+organizations/sentinel+event/se_pp.h
tm. Accessed April 2005
2
TIPS- official patient safety newsletter of the
Department of Veterans Affairs
July/August, 2004 - “How to Make the
Most of Actions and Outcome Measures,”
http://www.va.gov/ncps/TIPS/Docs/TIPS_J
ulAug04.pdf. Accessed April, 2005

PATIENT SAFETY LINKS

Interesting Resources To Explore

Bedside Manners
David Watts, M.D.
www.amazon.com
Book of vignettes exploring the world of modern-day medicine
by Dr. David Watts, a published poet and a regular commenta-
tor on NPR’s All Things Considered. Enjoyable and thought-
provoking read.
Institute for Healthcare Improvement
www.ihi.org
“Putting Safety on the (Central) Line”
Discussion of catheter-related bloodstream infections (CRBSIs)
and IHI Collaborative, as part of the100,000 Lives Campaign, to
reduce their incidence with the Central Line Bundle, a protocol
comprising five essential elements of central line management.
“Patient Centered Care” (click on “Topics”)
IHI initiative, supported by the Rx and Robert Wood Johnson
Foundations, to identify best practices and promising system
changes that enable patient-centered care. As part of this work
in progress, IHI is focusing on three themes: involving patients
and families in the design of care; reliably meeting patient’s
needs and preferences; informed shared decision-making.
Journal of the American Medical Association
www.jama.com
“Role of Computerized Physician Order Entry Systems in Facil-
itating Medication Errors”
March 9, 2005. Vol 293, No. 10, pp. 1197-1203.
Comprehensive, multimethod study. Identifies 22 situations in
which CPOE increased the probability of prescribing errors;
offers recommendations for organizational efforts to address
and reduce these errors.
“Error Reporting and Disclosure Systems”
March 16, 2005. Vol. 293, No. 11, pp. 1359-1366.
Study examines opinions and experiences of hospital leaders
with state reporting systems. Results reveal serious reservations
about these systems; authors suggest strategies for quality
improvement in reporting systems.
Annals of Internal Medicine
www.annals.org
“Fumbled Handoffs: One Dropped Ball after Another”
March 1, 2005. Vol. 142, No. 5, pp. 352-358.
Part of the “Quality Grand Rounds” series, this case report of
missed follow-up of abnormal test results, resultant delay in
diagnosis and a series of systems problems including poor con-
tinuity, lack of communication and several hand-offs is
extremely informative and readable, combining details of an
actual case with in-depth, generalized discussion of safety
issues, research and recommendations for improvement.
The New England Journal of Medicine
www.nejm.org
April 21, 2005. Vol. 352, No. 16
“Physician-Assisted Suicide—Oregon and Beyond”, pp. 1627-
1630
“Terri Schiavo—A Tragedy Compounded”, pp. 1630-1633
“Culture of Live Politics at the Bedside—The Case of Terri Schi-
avo”, pp. 1710-1715
These articles, taken together, provide a review of moral, politi-
cal and legal issues regarding end-of-life decisions.
Health Affairs
Web Exclusives, A Supplement to Health Affairs
www.healthaffairs.org
“The End of the Beginning: Patient Safety Five Years After ‘To
Err Is Human’”
July-December, 2004. Vol. 23, Supp. 2, pp. 534-545.
This review of progress in patient safety since the 1999 IOM
report offers a report card on what the author considers the five
major areas of activities and initiatives that have marked the past
five years: regulation, error reporting systems, information tech-
nology, the malpractice system, workforce and training issues.

4 SPRING 2005 PATIENT SAFETY

 NEWS FROM THE PATIENT SAFETY CENTER
Experiences and Suggestions From the Field
Enhancing
Medication Safety
At NH Rota
Data Clean-Up  Naming Standard-
ization  Pharmacy Layout  Shelf
Labeling  Medication Safety Shelf
Labels
Jody A Dreyer, LT, MSC, USN
Pharmacy Department Head
USNH Rota, Spain
OVERVIEW
A typical Navy Hospital Pharmacy main-
tains an inventory of well over 1,000 line items.
In the case of U.S. Naval Hospital, Rota, Spain
our current inventory is over 1,300 line items.
In all Navy Pharmacies, the pharmacy produc-
tion system, Composite Health Care Systems
(CHCS), does not communicate with the
pharmacy supply system, Defense Medical
Logistic Standard Support (DMLSS), and there
is no universally accepted standardized naming
convention among systems. Furthermore, over
time, the data integrity of the “drug files” in
CHCS and DMLSS degrades in many sites.
Several things can cause this degradation in
data integrity including, but not limited to: the
system lacking enough checks and balances to
support/force accurate data entry; lack of for-
mal training sufficient to maintain the drug
files in CHCS; the need for each site to
build/maintain its own drug files; and the lack
of someone in the pharmacy who possesses a
deep understanding of the different systems’
files and tables.
At the inception of the medication
enhancement project, USNH Rota’s CHCS
drug file had over 3,000 line items, the DMLSS
supply system for pharmacy was disorganized,
labeling of the stock shelves was erratic, there
was no standardized naming convention, and
there was an inconsistent process of drawing
attention to line items that were higher risk
and/or easily confused. To rectify these issues,
the pharmacy set out to standardize names and
stock locations; clean up the raw drug file data
in both CHCS & DMLSS; lay out the pharma-
cy stock in an organized, “easy-to-train”
methodology; and add attention-grabbing
labeling to those line items identified as High
Risk or easily confused.
PROJECT GOALS
1. Implement a solution that required less
time to use, was easier to train people to
use, was safer and able to be maintained
going forward.
2. Standardize drug names in CHCS and
DMLSS.
3. Limit viewable line items in CHCS by
providers and pharmacy personnel to
those items currently stocked.
4. Identify high and low stocking objectives
based on historical demand, scope of serv-
ices, contingency needs and the overseas
location of our pharmacy.
5. Decrease the not-in-stock rates to prevent
potential lapses in therapy.
6. Layout the pharmacy stock in sections so
that that pharmacy personnel, both new
and current, could readily find products.
7. Label 100% of the medication line items in
the pharmacy with a standardized naming
convention and stocking objectives.
8. Add attention-grabbing labeling to those
items with a higher potential for mix-ups
and/or to cause harm.
METHODS
An Access database was developed to assist
in standardization and to provide a tool for
developing shelf labeling, inventory books, a
locator book and to support other data driven
decisions for an upcoming pharmacy automa-
tion project. The Access database also provided
an updatable method to efficiently adjust stock-
ing levels based on CHCS workload as com-
pared to methods offered by the DMLSS system.
The first step in the process was identifying
needed line items and standardizing drug
names in CHCS. Drug names were standard-
ized on generic names and formatted so that
different strengths of a product would typical-
ly sort from lowest to highest strengths. In the
case of items that had zero usage and question-
able necessity, the pharmacist discussed the
specific product with the appropriate physician
(i.e. an obstetrics medication was discussed
with the Department Head of OB, etc.) for
PATIENT SAFETY SPRING 2005 5
necessity to maintain supply on hand.
The second step involved importing his-
torical CHCS usage data into Access to deter-
mine stocking levels and shelf section layouts
(i.e. Topical Section, Injectable Section, etc.).
In the third step, the pharmacy was reor-
ganized, first by stocking location and then A-
Z within that location by the CHCS standard-
ized name. Shelving labels, an inventory book,
and a stock locator book were created in Access
from the standardized naming convention. An
example of a typical shelf label is below:
CYNAOCOBALAMIN (VIT B-12)
1MG/ML IN J 1ML
High: 3
Unit of Inventorying
Low: 2
bxs of 25 vials
Injectables
If desired, Access has the capability to print
a barcode readable by the DMLSS hand-held
scanner. Or, the site can choose to use the stan-
dard DMLSS label. However, the standard
DMLSS label has limitations on field sizes,
which make it difficult to use non-abbreviated
descriptions. Using our Access database, we can
make the names and units of inventory explic-
itly clear, even for new personnel with zero
supply experience. In order to prevent the
labeling from quickly deteriorating, a “weath-
er-proof” label stock was used which does not
smear or fade over time and can easily be
peeled off for new labels with updated infor-
mation.
The fourth step involved using the CHCS
standardized names along with
the shelving section layouts to
standardize both the DMLSS
drug name and stock location.
As a fifth step we added
attention-grabbing labels to
those items either identified by
BUMED or locally as higher
risk and/or more easily con-
fused (i.e. Sound-Alike, Look-
Alike, etc). Again, “weather-
proof” labels were used. To the
left are the attention-grabbing
labels currently used at NH
Rota.
The sixth and ongoing
step involves maintaining data
integrity going forward. New
products are screened by the
Continued on Page 6
Medication Safety
Continued from Page 5
pharmacist to ensure that CHCS, Access and
DMLSS data integrity is maintained.
RESULTS/DISCUSSION
Enhancing the data integrity and standard-
izing the naming conventions at USNH Rota,
Spain have resulted in a safer and more effi-
cient medication management system. For
purposes of historical record keeping, the
CHCS drug file here had grown to over 3,000
line items, which in many cases were still view-
able by providers and pharmacy staff. Now,
only those items that are currently needed,
about 1,300 line items, are able to be viewed by
providers and pharmacy personnel, thereby
greatly reducing the “noise” involved in the
electronic drug selection process and reducing
opportunities for wrong drug selection.
In addition, since the naming convention
was standardized from CHCS to the stock
shelves to DMLSS, pharmacy personnel are
better able to immediately locate the needed
product. From a training standpoint, it makes
it easier for incoming pharmacy personnel to
find drug products, thereby speeding up their
learning curve. And, incoming providers can
be advised that being able to “pull up a drug in
CHCS” equates to the pharmacy having the
medication on hand.
The process of inventorying the pharmacy
has also been greatly enhanced. Prior to this
project, a pharmacy technician would “walk-
the-shelves” and handwrite which items were
AHRQ Patient Safety Network
New Website Offers Wealth
of Information
A
new website – the AHRQ Patient Safety
Network (PSNet) – was recently
launched by the Agency for Healthcare
Research and Quality (AHRQ). For patient safe-
ty professionals interested in keeping up with
developments in the field, but discouraged by the
sheer volume of information out there and the
difficulty in sifting through it for kernels of prac-
tical or policy significance, this site promises to
offer some much-needed “one-stop shopping”.
The site features a “What’s New”section with
an annotated compilation of the most recent and
important patient safety news, research, tools
and conferences. “The Collection” includes
thousands of patient safety resources, while
“Classics” is home to the most enduringly
important articles and books on patient safety. A
unique feature of PSNet allows each reader to
needed, based in most cases, on experience.
Due to the high turnover of active duty person-
nel, the effectiveness of this process was time
consuming and minimally adequate, at best.
Now, the process is guided by a robust invento-
ry book and historical, data driven stocking
requirements. Every medication item stocked
has an identified shelf location and stock levels.
Prior to implementing the new processes, a
burst in demand typically resulted in a stock
out. Now, with the stocking levels clearly post-
ed, every person in the pharmacy can con-
tribute to identifying when an item crosses the
reorder threshold, thereby minimizing stock
outs.
Building a supply order in DMLSS is now
much more efficient as the same stocking loca-
tions and alphabetization used in other areas of
the pharmacy are also used in DMLSS. An
accurate, weekly wall-to-wall inventory and
order can now be compiled in about 3 to 4
hours, whereas before a technician would
spend days inventorying and compiling an
order that typically did not capture all invento-
ry needs.
The addition of attention-grabbing label-
ing to a select subset of pharmacy items has
helped to provide increased awareness of those
items most likely to cause harm and/or confu-
sion. They also serve as a method to quickly
train new personnel on those items requiring
extra caution.
For more information, contact:
jadreyer@rota.med.navy.mil
0034 956.82.3565
customize the site around his or her own inter-
ests.
A sample of recent listings includes reports
of two studies, one on the effect of executive walk
rounds on nurse safety climate attitudes; the
other on the impact of a computerized rounding
and sign-out system on continuity of care and
resident work hours. Articles focused on ambi-
guity and workarounds, dosing errors in fibri-
nolytic therapy and latrogenic events resulting in
intensive care admission, and parents’ percep-
tions of pediatric day surgery risks.
According to Robert M. Wachter, MD, the
editor of PSNet and AHRQ WebM&M,“our aim
is to provide a rich exposure to cases, commen-
taries, and the world’s literature and tools in
patient safety”.
To receive the PSNet newsletter, which high-
lights what’s new each week, simply access PSNet
at http://psnet.ahrq.gov and click on “Subscribe
to Newsletter”.
6 SPRING 2005 PATIENT SAFETY
PATIENT
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 on the
progress of the DoD Patient Safety Program.
DoD Patient Safety Program
Office of the Assistant Secretary
of Defense (Health Affairs)
TRICARE Management Activity
Skyline 5, Suite 810, 5111 Leesburg Pike
Falls Church, Virginia 22041
703-681-0064
Please forward comments and suggestions
to the editor at:
DoD Patient Safety Center
Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100
Silver Spring, Maryland 20910
Phone: 301-295-7242
Toll free: 1-800-863-3263
DSN: 295-7242 • Fax: 301-295-7217
E-Mail: patientsafety@afip.osd.mil
Website:https://patientsafety.satx.disa.mil
E-Mail to editor: poetgen@aol.com
DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM:
CAPT Deborah McKay
DIRECTOR, PATIENT SAFETY CENTER:
Geoffrey Rake, M.D.
SERVICE REPRESENTATIVES:
ARMY:
LTC Steven Grimes
NAVY:
Ms. Carmen Birk
AIR FORCE:
Lt Col James Cockerill
PATIENT SAFETY BULLETIN EDITOR:
Phyllis M. Oetgen, JD, MSW
DoD PATIENT SAFETY WEBSITE
The DoD Patient Safety Website is accessible
at: https://patientsafety.satx.disa.mil. This
source of the most current information
about the Patient Safety Program and its
components is frequently updated, and
should be checked regularly. Features
include messages from CAPT Deborah
McKay, Director of the Patient Safety Pro-
gram, which review accomplishments and
announce new initiatives. The calendar of
events lists all levels of patient safety training
offered by CERPS and provides a link for
registration. Patient Safety marketing and
educational materials to increase patient
safety awareness among patients and
providers can be ordered from the website.
The Patient Falls Reduction Toolkit is now
posted. It can be downloaded and adapted
for individual MTF use. All DoD patient
safety providers are encouraged to make fre-
quent access to the Patient Safety Website a
routine part of their practice protocol.