1. Department of Legal Medicine Armed Forces Institute of Pathology
Patient Safety Center
Department of Legal Medicine
Armed Forces Institute of Pathology
Feedback and Reports
Explain what quality was nearly 20 years ago
Show Sweatshirt with logo and--PFNNKA
How that mentality has stayed with us.

2. Armed Forces Institute of Pathology
1. TriService
2. Mission: Consultation
Education
Research
Recommended several steps to unify the Nation in improving the quality of healthcare
Report noted that many organizations, including several Federal agencies were involved in important efforts to improve quality, but the lack of coordination made it difficult for healthcare providers and was confusing to the public

3. Department of Legal Medicine
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, for first offense
up to $20, 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 Access/Excel
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
- 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
phone: or 7242
fax:
beeper: