Preventing Medical and Surgical Errors
in the Department of Defense Military
Health Care System
Colonel Mark F. Torres, MD
Chairman of Ophthalmology
Ophthalmology Consultant to the US Army
Surgeon General
Madigan Army Medical Center
Tacoma, Washington
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)!
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!
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
High Risk Environment
► Wrong
► Wrong
► Wrong
► Wrong
► Wrong
► Wrong
patient
site
side
procedure
personnel
equipment
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
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
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
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
Questions / Comments
Thank You !!