Patient safety year-round process

  • Published
  • By Master Sgt. Richard B. Searles
  • Air Force Surgeon General Public Affairs
Although the National Patient Safety Foundation celebrates Patient Safety Awareness week in March, Air Force Medical Service officials take it on as a year-round process.

“Delivery of safe and effective patient care hinges on the integration of a continuous process designed to detect, assess, eliminate and/or control actual and potential risk to patients and staff, while enhancing performance,” said Lt. Col. Beth Kohsin. She is the Air Force patient safety program manager with the Air Force Medical Support Agency.

Medical service officials said they have taken a proactive approach when it comes to patient safety. One of these approaches is through education and training.

Colonel Kohsin has been traveling to military installations to educate servicemembers on medical-team training, an initiative designed to reduce the risks of errors associated with communication and teamwork in health care.

Communication continues to be the No. 1 contributing factor to preventable medical events causing harm to patients.

“(AFMS officials are) striving to modify basic beliefs on how to deliver safer and more effective health care,” Colonel Kohsin said. “We’re doing this by identifying and changing the real sources of operational vulnerabilities, or those points in the delivery of care where processes and systems are most likely to fail and cause harm to patients and staff.”

Colonel Kohsin said they are constantly reminding people that patient safety is the application of operation risk management to health care.

“Before (a) member of the health-care team does anything, (he or she has) to assess the risk inherent in that process,” Colonel Kohsin said. “After assessing that risk, (he or she) must then decide if the risk is acceptable.

“Each individual in the AFMS is responsible for identifying potential and actual risks and choosing the appropriate course of action for any given situation,” she said. “If the risk identified is acceptable, continue. If the risk to patient or staff is too high, or unacceptable, other actions must be identified, and an action with more acceptable risk must be performed.”

Colonel Kohsin said risk decisions should be based on the question, “Which is greater, the risk of doing this or the risk of not doing it?”

Commanders are responsible for routine application of risk identification, risk reduction and avoidance, and risk management in the planning and execution of all aspects of health care, from support to direct care activities, she said.

“The greatest opportunity to control risk is in the planning stages of any process or activity,” Colonel Kohsin said. “We’re teaching people to really look at a system and try to figure out exactly what’s going on. They’re looking for things that may be setting people up to fail by allowing error to get through to the patient and cause harm. The key is to identify those things before harm actually occurs. “

Although training has been going on for a few years now, Colonel Kohsin said they are about to take the training to the next level.

“We are working toward every member of the AFMS helping create a nonpunitive, learning culture by focusing on improved communication and cooperation, (on) systems and processes rather than individuals, and (on) prevention rather than punishment,” Colonel Kohsin said. “We are revising our guidance to use the risk identification, risk reduction [and] elimination, and risk management framework as the framework from which we operate.

“All key functions related to patient safety, clinical quality management and risk management are being aligned according to the model to show that the AFMS already does much of what is involved with patient safety,” she said. “However, we need to take it to the next level by swinging more toward the risk identification and elimination end of the continuum.”

Another step in improving patient safety in the Air Force is hiring patient safety contractors. The Air Force currently has 37 patient-safety contractors positioned throughout the medical service, stateside and overseas. The contractors are helping local officials begin taking a proactive stance.

With more than 60 percent of preventable medical events and near misses in the military involving some aspect of the medication process, the Air Force has focused a lot of its attention on pharmacy operations.

"The Air Force is currently the only service to standardize pharmacy automation," Colonel Kohsin said. "Through this automation initiative, which includes bar coding and visual imagery technology, (officials are) able to verify that medications dispensed to patients are the ones prescribed."

Although the use of robotics and automation reduces the chance for error, the most valuable asset when it comes to patient safety is people.

“I don’t see us replacing humans with technology in every facet of health care, so we have to focus on redesigning the processes and systems to support the people doing the jobs," Colonel Kohsin said. "Redesigning systems so that if a human does err, the process or system is built to detect and mitigate that error before it reaches the patients.”