Patient Safety Center Department of Legal Medicine Armed Forces Institute of Pathology

1. Patient Safety Center Department of Legal Medicine Armed Forces Institute of Pathology Feedback and Reports

2. Armed Forces Institute of Pathology 1. TriService 2. Mission: Consultation Education Research

3. Department of Legal Medicine • 1970-1990 - Risk Management case review and Education (lessons learned) • 1990-Present - Tort II, Clin II (Periodic ad hoc reports) • Legal Medicine : Annual publication, 5 CME credits, > 20,000 annually

4. Patient Safety Center at AFIP • MHS Patient Safety Registry at AFIP • Anonymous - No patient, provider, or facility names • Reports • monthly statistical report of summary data (near misses and adverse events) • quarterly statistical report based on aggregate reviews (medications and falls) • quarterly statistical report based on submitted RCA’s • lessons learned - later

5. Patient Safety Center Patient Safety Registry is to be used exclusively for the purpose of improving the health care systems and processes. It may not be used for adverse administrative privileging or other personnel actions.

6. Patient Safety Center Patient Safety Registry is protected as a Quality Assurance database under 10 USC 1102.

7. DoD Quality Assurance Statute 10 USC 1102 • Protects DoD Medical Quality Assurance Records from discovery • QA records are exempt from FOIA requests • Fines for Willful Closure • up to $3,000.00 for first offense • up to $20,000.00 for subsequent offenses

8. Current Patient Safety Center Staff • 2 Physician-Attorneys • 2 Physicians (part-time) • 1 Nurse Attorney with PhD in education • 1 Attorney • 1 Statistician • 1 Database Administrator • 2 Secretaries

9. Patient Safety Registry Future Staff Pending DoD (HA) Funding • Physicians • Nurse Risk Managers • Epidemiologists • Pharmacists • Training Managers • Programmers • Safety Engineers

10. Goals for Pilot Test Reporting • Test the format of reporting • Count the events by class • To allow the facility to compare its data with DoD-wide and/or Service-wide data • Construct database for the future • Increase the confidence and awareness of participants and institutions

11. Database Development • 4 separate databases • Root cause analysis • Falls • Medication Errors • Summary data • Access/Excel • More advanced development with funding

12. Patient Safety Center Statistical Reports • DoD-wide and Service-specific • Reports provided to: • Assistant Secretary of Defense (Health Affairs) • Executive Director of TMA • Secretaries of the Military Departments • Surgeons General of the Military Departments • President of USUHS • Each MTF Commander

13. Patient Safety Center Statistical Reports • Descriptive purpose • Some QI value - comparative use for facility • Developing error rates - difficult • Numerators are not accurate (voluntary reporting) • May eventually establish a baseline against which to compare future data

14. Monthly Statistical Report of Summary Data For events included on Summary Data Form: • Categories of events. • Contributing factors count for each event category. • Display of SAC categories.

15. Quarterly Statistical Data from Root Cause Analysis Statistical items that could possibly be reported are counts and percentages of the following: • service • hospital size • dates • SAC score • types of immediate actions performed • location in facility

16. Quarterly Statistical Data from Root Cause Analysis • Types of errors reported with contributing factors. • Types of errors with corrective actions. • Communication factors. • Training factors. • Fatigue/scheduling factors.

17. Quarterly Statistical Data from Root Cause Analysis • Environment/equipment factors. • Rules, policies, procedures factors. • Barrier factors. • Corrective actions.

18. Quarterly Statistical Report Based on Aggregate Reviews • Falls • Medication Errors

19. Patient Safety Alerts and Lessons Learned • Narrative concerning event(s), root cause(s), and corrective action(s) with references used. • Immediate and routine. • Report on collection of RCAs. • Will require a more mature, developed database with which to do analysis.

20. Sources of Lessons Learned Examples • Department of Energy • Department of Veterans Affairs • JCAHO • Notice To Airmen

21. Patient Safety Center AFIP will participate on the Patient Safety Council which shall review the reports from AFIP, Patient Safety Initiatives in the MHS, other agencies, and the private sector.

22. Patient Safety Council Membership • DoD (HA) • TMA • Military Departments • USUHS • DoD (General Counsel) • AFIP

23. Patient Safety Center MHS Patient Safety Registry Information will be available to Assistant Secretary of Defense (HA), the Secretaries of Military Departments, the Surgeons General, the Executive Director of TMA, the President of USUHS, the MTF Commanders.

24. Patient Safety Center AFIP also will monitor patient safety activities in other federal agencies, state governments, and non-governmental health care organizations.

25. Types of Dissemination • E-mail - Distribution lists • Hard copy • Web • Publication of statistical data

26. Long Term Issues 1. QUIC Feedback Committee 2. Possibility of lessons learned with CME, CEU 3. Patient Safety Publication 4. Surveys to determine usefulness 5. Reports will evolve based on your comments and suggestions 6. Collaboration with USUHS

27. Pilot Test • A good opportunity for you to provide input into the data collection effort. • Handbook, RCA form, AFIP reporting, etc. are all in the draft stage. • Encourage comments on data collection and contents of reports.

28. Point of Contact at AFIP Richard L. Granville, MD, JD Deputy Chairman, Department of Legal Medicine, AFIP 8403 Colesville Rd, Suite 860 Silver Spring, MD 20910-9813 phone: 301-295-8129 or 7242 fax: 301-295-7217 beeper: 301-517-6675 e-mail: granvill@afip.osd.mil