INSIDE: DoD Combat Care Incorporates Patient Safety Fundamentals

SPRING 2008 A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY

TEAMSTEPPS GOES TO WAR

Simulation Training at Home, Hands-On Training in Iraq Make System Combat-Ready

T
eamSTEPPS, the evidence-based team-training system developed by the DoD Patient Safety Program in collaboration with the
Agency for Healthcare Research and Quality (AHRQ), is fast becoming an integral part of combat-casualty care in Iraq. The Team-
STEPPS curriculum has been adapted to meet the needs of physicians, nurses, medics and other health-care professionals in the Iraq
theatre of operations. Providers are taught fundamental TeamSTEPPS concepts such as briefs, huddles and the SBAR handoff communi-
cation model. State-side simulation training prior to deployment and real-time use of TeamSTEPPS in theatre are combining to make
TeamSTEPPS a combat-ready tool to improve patient safety at the earliest point of medical intervention.

The story of TeamSTEPPS at war is the story of military medical administrators and providers collaborating to offer wounded warriors
the best and safest medical care from the moment of injury. The experiences described below — of the 86th Combat Support Hospital
(CSH) in Baghdad and the 947th Forward Surgical Team (FST) training here at home — tell the TeamSTEPPS story best. In the telling,
they affirm the power of TeamSTEPPS to improve patient safety and the determination, strength and dedication of the Military Health
System to the care of its patients.

Surgeons and support staff from the 86th CSH Task-Force Baghdad. Pictured left to right, front to back: CPT Dena George, COL Peter
Napolitano, MAJ Kevin Chung, MAJ Brian Themann; (2nd row) MAJ Jeffrey Henning, MAJ Dawn Elliott, LTC Booker King, MAJ Patrick Hickey, LTC
Michael Meyer (blue scrubs); (3rd row) LTC Jon Stineman, MAJ Mark Aierstok, LTC Steven Svoboda, LTC Anthony Allen, LTC Michael Mulreany, MAJ Todd
Baker (by sign), MAJ William Ralston, CPT Jason Cohen, COL Richard Stack (blue scrubs).

SPRING 2008

5 Patient Safety Week Activities

5 Call for Patient Safety Awards
6 Patient Safety Website
TEAMSTEPPS
GOES TO WAR
Continued from Page 1

The 86th Combat Support Hospital,

Baghdad, Iraq
Bringing TeamSTEPPS to the Front Lines

Since February of this year, the 86th Com-

bat Support Hospital (CSH) Task-Force
Baghdad has enjoyed the extra Team-
STEPPS advantage in its quest to safely treat
and transport the casualties of war in Bagh-
dad. February marked the arrival of COL
Peter Napolitano, Director of the Maternal-
Fetal Medicine Fellowship at Madigan
Army Medical Center and long-time Team-
STEPPS champion. Prior to deployment for
his tour at the 86th CSH, COL Napolitano
assessed the use of TeamSTEPPS in theatre.
Finding that there was no formal imple-
mentation, he explored with Command the
possibility of introducing TeamSTEPPS.
With the enthusiastic backing of leadership,
COL Napolitano worked with the Patient
Safety Program’s Health Care Team Coordi-
nation Program (HCTCP) to have Team-
STEPPS material shipped to Iraq. He then
faced the challenge of how to train trainers
and staff in the busiest combat hospital in Hospital staff see soldier off to next echelon of care in Balad after stabilization and treat-
the world. ment at the 86th CSH Task-Force Baghdad.

The traditional TeamSTEPPS two and one

half day Train-the-Trainer course and
four to six hour Train-the Participant
phase clearly would not fit the high acuity
CSH environment. Over two weeks of
periodic classes, COL Napolitano trained
forty-five representatives from every unit
of the hospital, fashioning an intense four
hour combined fundamentals and
instructor curriculum. With this initial
cadre of coaches in place, he began a
twice weekly concept release program. As
each TeamSTEPPS concept was intro-
duced, coaches modeled behavior and
staff incorporated and adapted the tool to
their particular unit.
Currently about one-half of the total CSH
staff in Baghdad has received formal
TeamSTEPPS training. An active interest
in TeamSTEPPS is palpable throughout
the hospital. COL Napolitano believes the
CSH, despite its challenges and unpre-
dictable routine, is uniquely suited to
embrace the TeamSTEPPS system. With
their sharp focus on casualty care and sin-
gle-minded purpose, staff members unite
TEAMSTEPPS ON THE LANDING ZONE
Tools Adapt To Any Setting
On a typical day the Combat Support Hospital receives several MASCALs with little down time in
between. All operating rooms are in use. The transport system is in full swing. Black Hawk heli-
copters are standing by to move patients to the Air Force’s Expeditionary Medical Group Hospital,
the next echelon of care on their journey to Landstuhl and eventually back home.
On this day two soldiers arrived at the staging area for transport, accompanied by ICU nurses, who
would fly with them and respond to any emergencies in flight. The flight-line check list had been
reviewed. The patients were ready for loading. Before they were settled in the chopper, the attend-
ing ICU physician unexpectedly arrived at the flight line. She hurriedly explained that she had
missed her usual TeamSTEPPS-inspired huddle before the patients left the ICU and that she wanted
to review the patients one last time with the nurses.
During the huddle she reminded the flight nurses that one of the patients had especially severe res-
piratory injuries. A special piece of equipment was determined to be necessary should he need to
be resuscitated in flight. This equipment, because it is rarely needed, is not included in standard
flight resuscitation sets. After the huddle, the crew made a special effort to find one and bring it on
board.
Fifteen minutes into the thirty minute flight,the soldier suffered a respiratory arrest. The accompany-
ing ICU nurse used the equipment in a successful resusitatation. In this case, the TeamSTEPPS hud-
dle highlighted an important piece of information for this soldier's care. In the combat care setting
success is not about a predetermined process, but is achieved by learning the TeamSTEPPS con-
cepts and adjusting them to work in the midst of the unexpected. The ICU physician's huddle on
the landing zone, right at the chopper door, underscores the adaptability of TeamSTEPPS tools and
their readiness for combat.

2 SPRING 2008 PATIENT SAFETY

around the same goal. They are particular-
ly open to trying new things and are able to
learn at an accelerated rate in the some-
what self-contained CSH environment.
Deputy Commander of Nursing (DCN)
COL Stephen W. Lomax, new to Team-
STEPPS himself, says he was quickly won
over to a system he feels improves patient
care. His nursing staff is receptive to things
they feel give them an advantage, especially
in the frequently high-stress atmosphere of
the CSH.
The practical application and value of
TeamSTEPPS in the combat zone has been
affirmed in the daily experiences of the 86th
CSH. With several hundred confirmed
rocket and mortar attacks in the Baghdad
area since January 2008, providers have
been known to receive two to five massive
casualty events (MASCALs) on a given day.
The hospital fills and empties daily. Victims
receive life-saving surgery and treatment
and then are transported to the next eche-
lon of care within one to twenty-four hours.
In this extremely high acuity atmosphere an
individual patient may be involved in ten to
fifteen handoffs. There is an understandably
increased risk of losing or overlooking a
critical piece of medical information
between a soldier’s transport from the bat-
tlefield by medical evacuation (MEDEVAC)
to the time he or she leaves the CSH from
the helicopter landing zone (LZ). Team-
STEPPS tools such as the SBAR, I PASS THE
BATON, briefs, huddles, check back and the
I’M SAFE check on situational awareness
provide structure and reliability in the
midst of such intense trauma.
As the TeamSTEPPS champion prepares for
his June departure, COL Napolitano has
great confidence that TeamSTEPPS will
become an organic part of the medical side
of Operation Iraqi Freedom (OIF). COL
Patrick D. Sargeant, Commander of the
62nd Medical Brigade, is an enthusiastic
advocate of its widespread use throughout
the theatre of operations. COL Napolitano
has assembled a strong support staff. MAJ
Michelle Munroe, a nurse Midwife from
Madigan Army Medical Center serves as
Emergency Medicine and Deployment
Combat Casualty Research Team (DCCRT)
Research Nurse at the 86th. She has been
critical to the success of TeamSTEPPS in
theatre and will become its Nurse Champi-
on going forward. MAJ Munroe, with the
assistance of COL Lomax and LTC Vivian
Ludi, Patient Safety Process Improvement
Officer, will expand the TeamSTEPPS train-
ing to the five other CSH units, eight For-
ward Surgical Teams and one Air Force hos-
pital in OIF.
With its champions in place, COL Napoli-
tano credits the dedicated health care
providers deployed to OIF as the real power
behind the TeamSTEPPS difference. In this
most challenging of all situations, he
explains “TeamSTEPPS provides workable
tools to an already strong system. It rein-
forces good teamwork behavior that good
leaders are already doing. TeamSTEPPS for-
malizes the good work we do and ensures
that we do it all the time”.
The 947th Forward Sugical Team
Training at Home to Deploy as a Team
The 947th Forward Surgical Team (FST)
from the West Hartford Reserve Center par-
ticipated in the first fully dedicated Team-
STEPPS simulation training March 7-9 at
the National Capital Area Medical Simula-
tion Center in Silver Spring, Maryland. Pro-
nounced a “fabulous success” by MAJ
Michael Gutman, 947 FST Commanding
Officer, team members spent a full day
working through scenarios that simulated
field experiences from triage to resuscita-
tion to transport.
The 947th Forward Surgical Team “brief”, assigning roles and responsibilities prior to
Day 2 of TeamSTEPPS Simulation training.
The 947th FST is in year three of a five year
training cycle, thus not in line for the Army
Trauma Training Center (ATTC) course
which integrates TeamSTEPPS concepts in
the intensive trauma curriculum offered to
deploying surgical teams. MAJ Gutman,
long interested in Crew Resource Manage-
ment, set out to explore team training
options available to the 947th as they hone
their clinical skills. He worked with Ms.
Heidi King, Director of the DoD Patient
Safety Program Health Care Team Coordi-
nation Program (HCTCP) and the Nation-
al Capital Area Medical Simulation Center
(Sim Center) staff to develop a Team-
STEPPS simulation experience aimed at
teaching team dynamics and communica-
tion skills to the FST. In December 2007,
HCTCP taught the FST TeamSTEPPS fun-
damentals in a weekend-long course adapt-
ed to support its up-coming simulation
training.
Upon arrival at the Sim Center on March
7th, the FST received a two hour refresher
course, along with an orientation to the Sim
Center. Saturday, March 8th was SIM DAY
— nine hours of training, broken into three
“Days”, each Day representing an increasing-
ly complex combat scenario. Battlefield
authenticity was achieved using the Sim
Center’s high-tech resources — a Wide-Area
Virtual Environment (WAVE) for triage
Article continued on page 4
PATIENT SAFETY SPRING 2008 3
training, with front line background, light-
ing and sound effects; a two-patient Resusci-
tation Bay and holding area; and a fully-
equipped Clinic. Twenty patients had been
hired, pre-trained and expertly made-up as
Members of the 947th FST practicing battlefield triage in the Wide Area Virtual Environ-
ment (WAVE) setting of the National Capital Area Medical Simulation Center.
MAJ Michael Gutman, Commanding Officer of the 947th Forward Surgical Team observ-
ing teamwork skills while FST members work on a patient in the Resuscitation Bay.
4 SPRING 2008 PATIENT SAFETY
trauma victims for the day. In addition to the
regular complement of Sim Center staff, the
faculty included three visiting physicians
who role-played, observed and critiqued the
team’s performance. Further input was pro-
vided using the Sim Center’s computerized
monitoring and evaluation process.
Debriefs following each “Day”, facilitated by
Sim Center staff, encouraged FST members
to reflect on their performance. Physician
faculty members and a nurse monitor who
had been briefed on TeamSTEPPS added
their observations, which were detailed and
process-directed. With comments such as “I
didn’t hear a callback” or “Did you use the
huddle”, they kept the focus on teamwork
fundamentals. They also challenged the FST
members on how they interacted with their
role-playing faculty. One physician, explain-
ing that she had been simulating a distract-
ing physician presence, encouraged team
members to rely on their teamwork skills
especially in the face of stressful, unantici-
pated challenges. As FST members moved
through their various scenarios, both they
and the Sim Center staff and faculty agreed
that communication improved and the use
of TeamSTEPPS-related tools increased.
MAJ Gutman believes the combined Team-
STEPPS/Simulation exposure at this time
in his FST’s training cycle is beneficial for a
number of reasons. The training strength-
ens the team bonds among members
(many of whom are new to the FST); it
breaks down barriers to communication
inherent in the military hierarchy which at
times are impediments to clinical care,
especially in high-stress situations; and it
integrates clinical skills in the environment
where the team will be receiving patients.
His goal, says MAJ Gutman, is to try to get
the FST members totally comfortable
working with each other well before they
deploy. Once they are in theatre, surgeons
or other officers will be plugged into the
team and rotated every few months. In
such a fluid environment, where a certain
amount of change is built in, the presence
of a shared mental model of performance
among the forward surgical team members
encourages skillful, reliable interaction
time after time, regardless of external chal-
lenges. This early training of a unified core
which has learned to function together will
increase the functionality of the FST, the
implementation of TeamSTEPPS tools and
the safety of patients and providers alike in
the real world of combat trauma care.
 PATIENT SAFETY IN ACTION
Experiences and Suggestions From the Field
MTFs CELEBRATE NATIONAL PATIENT SAFETY AWARENESS WEEK
March 2–8, 2008 Observed With Posters, Awards, Games and Patient/Provider Camaraderie
20 MDG: Shaw AFB, South Carolina
Poster from Shaw AFB, where the National
Patient Safety Week (NPSW) poster contest was
inspired by information included in the Ambula-
tory Patient Safety Goals. Congratulations to
TSgt Ollet who received a one-day pass for his
first-place effort, shown above.
Munson Army Health Clinic
Fort Leavenworth, Kansas
Munson Army Health Center, Fort Leavenworth,
KS recognized three services for outstanding
achievement in Patient Safety during National
Patient Safety Week: Radiology — highest near
miss/good catch reporting; Laboratory — high-
est over-all reporting of Patient Safety events;
Operating Room — 100% compliance with The
Joint Commission’s Universal Protocol for all
surgical procedures. Each Service was presented
with a specially designed plaque featuring the
DoD and AMEDD crests. Pictured are staff
members from the three clinics.
90 MDG: Warren AFB, Wyoming 27 SOMDG: Cannon AFB, New Mexico
Capt. Lisa Lee, Clinical Pharmacy Services Pediatric dosing spoons, pill containers and
Chief, 90th Medical Support Squadron, instructs poison control brochures were displayed and
pre-schoolers from the F.E. Warren Child Devel- distributed during National Patient Safety Week
opment Center on the fundamentals of clean in the atrium of the 27SOMDG. Staff observed
hands as part of the 90th MDG NPSW outreach the week with daily patient safety emails and
efforts. In addition to hand hygiene, the 90th an electronic patient safety Trivia Contest.
MDG encouraged patients to share responsibili-
ty for satisfactory clinic appointments by bring-
ing a list of medications and by keeping an
appointment notebook.
377 MDG: Kirtland AFB, New Mexico 35 MDG: Misawa AFB, Japan
Terry Duke, Patient Safety Manager, meets Ms. Patient Safety Manager Paul Sayles is inter-
Doris Joy, the Medical Group’s Health Benefits viewed by the local Air Force Network morning
Advisor to plan the distribution of the National DJ about Patient Safety Week and medication
Patient Safety Foundation brochure on the reconciliation. The station aired spot patient
patient’s role in making healthcare safer. During safety announcements during Patient Safety
Safety Week, the brochure was given to patients week. The 35 MDG also hosted a staff treasure
while they waited for appointments and pre- hunt for patient safety errors and sponsored a
scriptions and explored their TriCare benefits. bulletin board contest featuring application of
patient safety goals within the hospital units.
CALL FOR PATIENT SAFETY AWARD SUBMISSIONS
Deadline is September 10, 2008
The Office of the chief Medical Officer (OCMO) at TRICARE Management Activity (TMA), sponsor of
the Department of Defense (DoD) Patient Safety Awards, is calling for submissions for the 2008 Patient
Safety Awards. Now in their sixth year, the Patient Safety Awards recognize efforts designed to improve
the care delivered within the Military Health System.
The deadline for awards submissions is SEPTEMBER 10, 2008. The awards will be presented at the
annual Military Health System (MHS) Conference, which is scheduled from November 30 to December
5, 2008. Access the Patient Safety Website: http://dodpatientsafety.usuhs.mil/patientsafetyawards to
download an Application Guide.
PATIENT SAFETY SPRING 2008 5
MTFs CELEBRATE NATIONAL PATIENT SAFETY AWARENESS WEEK
March 2–8, 2008 Observed With Posters, Awards, Games and Patient/Provider Camaraderie Continued from Page 5

374 MDG National Patient Safety Week Treasure Hunt List

8. Locate your nearest Crash cart. What items are kept in Drawer C?
1. List the location of at least two fire extinguishers in or closest to your
department.
______________________________________________
______________________________________________ _________________________________________________________

2. What is the middle initial of the Patient Safety Manager?_________
3. Locate a Patient Rights Poster. What is the 4th right listed?
______________________________________________
______________________________________________
4. What MDGI empowers staff to notify his/her supervisor if he/she has
conflict caring for a patient? What is the MDGI and paragraph
number? (Hint: staff rights and organization ethics)
______________________________________________
______________________________________________
5. If applicable, where is the main 02 shut-off within your department?
Who can shut it off in the event of an emergency?
______________________________________________
______________________________________________
6. When is the next Hospital Newcomer’s Orientation held? _________
7. Where is the shredder closest to your department?
______________________________________________
______________________________________________
9. What is the memo called to report an unusual occurrence, a
medication error or clinical mishap? (Hint: mnemonic describing
situation, recommendation, follow up and trends)?___________
10. Where is the Medical Control Center set up in a disaster? (Hint: The
Disaster Team Chief Emergency Plan binder).
______________________________________________
______________________________________________
11. Find the TeamSTEPPS™. What is the tool listed on page 27 (17
for 1st Edition pocket guide) used to help communicate critical
information that requires immediate attention and action requiring a
patient’s condition? (Hint: can be used during hand-offs)
______________________________________________________
12. How long do you have to complete an Event Report? (Hint: MDGI
44-138 Patient Safety Program)____________________________
13. How do you know if a provider or surgeon is privileged to perform a
specific procedure? (Hint: Can Dr. Pike do an appendectomy?)
______________________________________________

3 MDG Naval Hospital, Bremerton 374 MDG

Elmendorf AFB, Alaska
Jeopardy host Jim Cahill, Director of Perfor-
mance Improvement, listens to an answer
from Capt Corey during a Squadron Jeopardy
game on March 5th. The game was designed
to help staff prepare for a summer Joint Com-
mission/ HIS inspection, with questions and
answers related to Joint Commission hot top-
ics and general HIS information. Staff
response was so enthusiastic that Executive
Leadership has requested another game be
scheduled in May.
Bremerton, Washington
Commanding Officer Catherine Wilson offi-
cially opens the Bremerton Patient Safety Cir-
cus by cutting the ribbon to the quarterdeck
display. Inside, patients and staff found circus
themed boards and props with patient safety
information, a Patient Safety Goal toss-a-cross
game and a Circus “Side Show” featuring a
petri dish sampler showing pre and post
hand-washing germ growth.
Yokota AB, Japan
The 374th MDG staged a facility-wide treas-
ure hunt for patient safety-related clues during
their National Patient Safety Week obser-
vance. The Pediatrics Department won the
contest with 100% participation from doctors
to administrators. Stress balls and pens with
the logo "Deliver Safe, Compassionate Quality
Healthcare" were given to all staff members
during the week.

PATIENT SAFETY WEBSITE PATIENT SAFETY

http://dodpatientsafety.usuhs.mil
Busier and Better Than Ever
As the revised Patient Safety Website marks
its first year in operation, a review of its use
and improvements underscores the integral
role it plays in communicating key elements
of the DoD Patient Safety Program (PSP).
Soon after its April 2007 launch, the website
recorded 2,000 plus visits per month.
March 2008 saw over 9,000 visitors, repre-
senting world-wide contacts ranging from
English-speaking countries like Australia,
Canada and the U.K., to the more exotic
locales of Europe, Asia and the Middle East.
Although the greatest percentage of visitors
(38%) come from U.S. Military sites, 29%
represent U.S. commercial users, with
smaller numbers from non-profit organiza-
tions and U.S. government sites. Informa-
tion relating to TeamSTEPPS is frequently
accessed, as is the DoD Fall Reduction Tool
and PSP education modules.
For those users who are part of the DoD Mil-
itary Health System, the website offers entry
to the full range of PSP initiatives, achieve-
ments and plans. User-group log-in capabili-
ty is now an established function on the web-
site. Interactive features have become a reali-
ty. The TeamSTEPPS Learning Action Net-
work (LAN) regularly posts its agenda and
power-point presentations on the website for
participants to access during conference calls
linking any number of remote sites.
The Patient Safety website is not resting on
its accomplishments. Under the direction
of PSP Webmaster/Developer Vienkhanh
(Khanh) Nguyen the site continues to add
content and new features. Going forward,
look for an even more user-friendly, visual-
ly arresting format. "It's all about the peo-
ple and making it easier for them to find
the information they're looking for", says
Webmaster Khanh.
Website usage by Country for March 2008
US Military 38%
US Commercial 20%
Network 15%
Unresolved/Unknown 15%
Non-Profit Organization 5%
US Educational 3%
US Government 1%
Australia 1%
Other 2%
PROGRAM NEWSLETTER
Published quarterly by the Department of Defense
(DoD) Patient Safety Center to highlight 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
Forward comments and suggestions to:
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: http://dodpatientsafety.usuhs.mil
E-Mail to editor: poetgen@aol.com
DIVISION DIRECTOR,
PATIENT SAFETY PROGRAM
COL Steve Grimes
DIRECTOR, PATIENT SAFETY CENTER
Geoffrey Rake, MD
DIRECTOR, CENTER FOR EDUCATION
AND RESEARCH IN PATIENT SAFETY
Eric S. Marks, MD
DIRECTOR, HEALTHCARE TEAM
COORDINATION PROGRAM
Ms. Heidi King
SERVICE REPRESENTATIVES
ARMY
LTC Robert Durkee
NAVY
Ms. Carmen Birk
AIR FORCE
Lt Col Anne Coyne
PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
Phyllis M. Oetgen, JD, MSW

6 SPRING 2008 PATIENT SAFETY