Preventing Medical and Surgical Errors in the Department of Defense Military Health Care System

1. Preventing Medical and Surgical Errors in the Department of Defense Military Health Care System

2. Colonel Mark F. Torres, MDChairman of OphthalmologyOphthalmology Consultant to the US Army Surgeon GeneralMadigan Army Medical CenterTacoma, Washington

3. Disclaimers • I wear the same clothes every day (i.e. government employee)! • I receive regular paychecks in very modest amounts (i.e. no financial interests)! • If the government wanted me to have an opinion, they would have issued me one (i.e. not official policy)!

4. Risk Factors for Patient Safety in Ophthalmology • Large patient volumes • Large number of short duration surgical procedures • Large amount of prosthetic device usage • One-sided surgery – even when bilateral!

5. Risk Factors for Patient Safety in Military Health Care System • Hospital-based practice – differs from civilian sector • Must work cooperatively across health professions, specialties, and locations • Variable personnel and turnover • Personnel in various training programs and at various stages of training

6. High Risk Environment • Wrong patient • Wrong site • Wrong side • Wrong procedure • Wrong personnel • Wrong equipment

7. Team STEPPS • Madigan Army Medical Center 2009 • Department of Surgery, Department of Anesthesia, and Department of Nursing in operating room environment • Premise – freedom of communication acts to counterbalance a risky environment • Goal – improve patient safety and outcomes through improved communication across the health care team

8. Salient Features • Brief – prior to surgery, all personnel • Time-Out – before any procedure begins, verify patient, procedure, side, site • Hand-Off – transfer patient care between health care personnel (SBAR format) • Out-Brief – identify any miscues on previous procedure

9. What Team STEPPS can do !! • Empower personnel • Improve communication • Prevent medical and surgical errors • Improve patient safety and outcomes • Break down old barriers and stereotypes • Complement and educate on risk management

10. What Team STEPPS will not do !! • Challenge leadership • Create perfection • Careful to avoid the “no defects – zero tolerance” mentality • Not designed to be used in a punitive fashion

11. Questions / Comments Thank You !!