Skip to main content

Military Health System

Important Notice about Pharmacy Operations

Change Healthcare Cyberattack Impact on MHS Pharmacy Operations. Read the statement to learn more. 

Patient Safety Awareness Week Highlights Ready Reliable Care

Image of Patient Safety Awareness Week Highlights Ready Reliable Care. The theme for the 2023 Patient Safety Awareness Week, March 12-18, is “Be a Patient Safety Hero: Anywhere, Anytime – Always.” While every day is a patient safety day for the Military Health System, a unique spotlight shines on this issue during this international education and awareness-building campaign.

The theme for the 2023 Patient Safety Awareness Week, March 12-18, is “Be a Patient Safety Hero: Anywhere, Anytime – Always.” While every day is a patient safety day for the Military Health System, a unique spotlight shines on this issue during this international education and awareness-building campaign.

Patient safety means treating every patient with the right treatment, at the right time, for the right reason, with all health care professionals maintaining the highest level of care to:

  • Identify patients correctly
  • Prevent infection
  • Improve staff communication
  • Identify patient safety risks
  • Prevent mistakes in surgery
  • Use medicines safely
  • Use alarms safely

“It's important to take time to focus on patient safety and being resilient in our daily practices,” said Heidi King, chief of the Department of Defense’s Patient Safety Program within the Defense Health Agency. “We value teams caring for patients every day and our cadre of patient safety professionals that support health care delivery in all military hospitals and clinics.”

Patient safety involves different tools and training that are increasingly digital as the MHS has realigned into markets and incorporated the MHS GENESIS electronic health record. This also includes the Ready Reliable Care Safety Communication Bundle, a set of six standardized, evidence-based safety practices published in January 2022 “designed to improve the culture of safety and reduce workplace-related stressors that contribute to burnout” among health care workers, said U.S. Navy Capt. Mary Parker, PSP’s patient safety solutions lead. “Overall, its goal is to reduce preventable harm.”

The MHS introduced the Ready Reliable Care approach in 2021 as a guide to increase high reliability across military hospitals and clinics, and improve health care access, quality, transparency, and patient engagement. DHA continues to gather data to understand the challenges facing military hospitals and clinics.

TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) and the Patient Safety Professionals Course are flagship learning opportunities to advance Ready Reliable Care.

“Standardization of safe care practices plays a key role in learning organizations,” King said. She noted that MHS partners with internal and external stakeholders, and beneficiaries to share lessons learned, leading practices, and other improvement opportunities for patient safety.

Patient Safety Culture

The 2022 DOD Patient Safety Culture Survey had 37,000 respondents across the MHS. The evidence-based survey measures safety culture across numerous patient safety dimensions, including organizational learning, teamwork, reporting of patient safety events, staffing and work pressures, staff well-being, communication, and leadership support.

DHA is working on a strategic plan that incorporates feedback from the surveys. In 2019, it added items to assess staff burnout and underlying cause factors, and these were expanded in 2022.

“The culture survey results are used to help drive MHS-wide improvement initiatives, as well as provide information to target more local efforts,” said Cherylann Robinson, lead of the Patient Safety Culture Survey in 2022. “Each military hospital and clinic that participated in the survey can access resources and data results to help shape improvements in their respective hospital cultures.”

Digital Tools and Patient Safety

Barcode medication administration technology reduces errors in health system settings by using barcode labeling of patients, medications, and medical records to electronically link the right dose of the right medication to the right patient at the right time. A study of non-timing medication errors in a system with comprehensive barcoding/electronic medical administration technology found a 41% reduction in errors and a 51% decrease in potential adverse drug events.

“Fort Leonard Wood was the MHS’s first medical facility to break the 95% Leapfrog survey benchmark threshold of reduction in medication errors in January 2023,” said Brian Anderson, PSP systems lead and Barcode Medication Administration Safety campaign action officer. Leapfrog is a national non-profit looking to achieve great leaps in patient safety.

“Many MTFs are showing major improvement, and as MHS GENESIS continues to expand to all MTFs, they acquire software and equipment to do [barcode] scanning for the first time,” Anderson said. “The process is supporting safer medication practices and engineering guard rails for staff to do the right thing every day for patient medication safety at the point of service.”

More Training Options

The Patient Safety Professional Course is comprised of Core Content and a Comprehensive Systematic Analysis agenda. PSPCs are conducted four times annually. TeamSTEPPS® is also a key aspect of patient safety.

“This course is continually updated and is a unique, virtual, adaptive learning event that has greatly expanded our ability to reach out to those who connect with our beneficiaries daily,” said U.S. Air Force Col. Maxine McIntosh, the PSPC lead.

“TeamSTEPPS® is an evidence-based framework used to optimize team performance. Created as a joint venture between the DOD and our federal partners at the Agency for Healthcare Research and Quality, the program has been critical in minimizing preventable harm to our beneficiaries,” said TeamSTEPPS® lead Joe Paulino. “We offer training opportunities with implementation guidance to medical and dental staffs to reinforce these team-based practices.”

You also may be interested in...

Policy
May 22, 2012

Memorandum: #12-005, Reporting Infection Prevention and Control Data to the Centers for Disease Control and Prevention using the National Healthcare Safety Network 12-005

.PDF | 121.58 KB

The purpose of this memorandum is to update Health Affairs Policy 08-020, which implemented the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) within the Military Health System (MHS).

  • Identification #: 12-005
  • Type: Memorandum
Policy
May 23, 2011

Instruction: Navy BUMED Instruction 6010.28: Healthcare Resolutions Program

This instruction establishes Navy Medicine strategic policy for the promotion of organizational transparency and full disclosure following unanticipated or adverse outcomes of care; to assist the enterprise in "doing the right thing" when there are unanticipated outcomes of care, treatment and services; to train and coach providers in disclosure ...

  • Identification #: N/A
  • Type: Instruction
Policy
Dec 18, 2002

Instruction: Navy BUMED Instruction 6010.23: Participation in the Military Health System Patient Safety Program

This instruction requires all shore-based commands providing medical and dental services, providing care, or participating in the health care delivery system to support the MHS Patient Safety Program.

  • Identification #: N/A
  • Type: Instruction
Policy
Oct 29, 1996

Instruction: #Navy BUMED Instruction 6010.21, Navy BUMED Instruction 6010.21: Risk Management Program

This instruction establishes policy and assigns responsibility for organizational risk management activities. It defines minimal requirements for proactive and reactive responses in naval medical and dental treatment facilities.

  • Identification #: Navy BUMED Instruction 6010.21
  • Type: Instruction
Last Updated: May 26, 2023
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on X Follow us on YouTube Sign up on GovDelivery