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

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Preventing Medical and Surgical Errors in the
Department of Defense Military Health Care System
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Colonel Mark F. Torres, MDChairman of
OphthalmologyOphthalmology Consultant to the US
Army Surgeon GeneralMadigan Army Medical
CenterTacoma, Washington
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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)!

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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!

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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

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High Risk Environment

• Wrong patient
• Wrong site
• Wrong side
• Wrong procedure
• Wrong personnel
• Wrong equipment

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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

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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

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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

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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

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Questions / Comments

• Thank You !!