WASHINGTON, DC—It is okay to admit a mistake. In fact, Air Force Col Christian Benjamin, commander of the 99th Medical Group at Nellis Air Force Base, is very pleased when personnel report medical errors and near misses because each error or near miss is an opportunity to improve patient safety. “We have been able to get this attitude out that no individual is perfect and that it is all a team effort,” said Benjamin.

It is this type of attitude towards patient safety that has helped the 99th Medical Group at Nellis Air Force Base gain recognition for its work toward improving patient safety with the 2008 AFMS Best Inpatient Facility Patient Safety Program and the 2009 AFMS Best Inpatient Facility Patient Safety Program awards, and the 2010 MHS Patient Safety-Culture Measurements, Feedback, and Intervention award.

Patient safety efforts are incredibly important to hospitals because there are so many opportunities for a patient to be put at risk. Benjamin said that progress in patient safety has been made at Nellis by not only encouraging personnel to report their errors, but also to provide information on their ’near misses.”

One example of a “near miss” is a pharmacy employee who nearly puts the wrong patient label on a bottle of medication but then realizes the potential error. When near misses are reported, it allows the hospital to examine whether a process, procedure, or other factor may need to be addressed to avoid future similar incidents. ’The more you can get near misses brought out into the light, the better able we are in looking at the processes that led to the near miss and making the process improvements, thereby preventing future errors,” said Benjamin.

Benjamin said they have really sought to encourage a culture of transparency at the facility in order to make people feel comfortable reporting errors and near misses. By cultivating a culture where people feel comfortable, he said reporting of events increased from 2008 to 2009 by 56% and the number of events that caused harm to patients decreased by nearly 73%.

DoD Tackles Patient Safety

DoD Patient Safety Program Director Army Lt Col Donald Robinson said that an increase in reporting, such as the 99th Medical Group has experienced, is what DoD program is seeking. While any facility can have zero errors by simply not reporting, this does not help shed light on areas that could put patients at risk. “We want to increase the number of errors reported. What we want to decrease is the amount of harm that is associated with the errors. We want near misses because near misses tell us that people are communicating, people are utilizing team work and are looking out for each other.”

His office, he said, is not out to “attack folks,” but is interested in focusing on the systems and processes that may need to be improved to avoid future problems. As a trauma surgeon, Robinson said he understands that reporting can be difficult. “I am a surgeon and it is difficult for me to say that I have made a mistake because I wasn’t trained to make mistakes.”

The way to help increase transparency of errors and near misses comes by changing the healthcare culture. “Instead of focusing on who, we need to focus on how. We need to focus on how the event happened and how we can avoid it in the future.”

Robinson said that his program is working to enable providers and facilities to improve patient safety through a variety of methods such as leadership engagement, training, coaching, supplying tool kits to providers, and risk identification and mitigation. A computerized patient safety reporting system is also being deployed. This will allow personnel to anonymously input error data into a computerized tracking system. Currently, the military health system uses a paper-based system for reporting patient safety events.

Tools to Promote Patient Safety

At Nellis, Benjamin said that the future of the patient safety at the hospital consists of maintaining focus on it. “If we don’t continue to remind them, then people will become complacent and you’ll see our statistics go in the opposite direction. The future is maintaining the gains we have made.”

In addition to encouraging patients and personnel to report anything of concern, the 99th Medical Group utilizes patient safety representatives, who are medical personnel from various areas, to work on patient safety in their units.

Benjamin said that there are also procedures and tools in place to help providers. Personnel, for example, use TeamSTEPPS to ensure that the right information regarding the patient is exchanged when patients are handed off from one set of providers to another set of providers. TeamSTEPPS is an evidence-based teamwork system designed to improve communication and teamwork skills among healthcare professionals that was developed by DoD in collaboration with the Agency for Healthcare Research and Quality (AHRQ). “Anytime we have providers treating a patient and then we hand that patient off to another set of providers those are vulnerable events because the new accepting provider doesn’t have the total picture as well as the person giving the handoff.”

The hospital also has a simulation lab that medical personnel can use to recreate scenarios that have been problematic. If, for example, a unit has had near misses with patient identification, the team can recreate the same situation in the simulation lab to determine how the team can refine its methods.

back to May articles