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RISK COMMUNICATIONS & NAVY UPDATE. Jeff Sherman Director, Medical-Legal Affairs BUMED. Case #1. Deployed Marine SGT Skin lesion Operational physician (GMO) Salve In garrison clinic consult lost No follow up for 4 months Stage 4 melanoma Family engaged congressman and national media.

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risk communications navy update

RISK COMMUNICATIONS & NAVY UPDATE

Jeff Sherman

Director, Medical-Legal Affairs

BUMED

case 1
Case #1
  • Deployed Marine SGT
  • Skin lesion
  • Operational physician (GMO)
    • Salve
  • In garrison clinic consult lost
    • No follow up for 4 months
  • Stage 4 melanoma
  • Family engaged congressman and national media
case 2
Case #2
  • Marine LCPL admitted with mediastinal mass, significant pain and anxiety
  • Dysfunctional family
  • Multiple drugs
    • Fentanyl transdermal patch
  • Hot shower; slept for 4 hours/coded/died
    • Patch discarded during code
  • Marine Corps leadership very concerned about quality of care
  • Local media
case 3
Case #3
  • MTF birth
  • Cord injury
    • Resuscitation delayed
  • Ventilation/fixed pupils
  • Provider insisted that life support be discontinued against family wishes
    • Morphine push
  • Parents/staff upset
  • NCIS
case 4
Case #4

79 yo MTF contract Radiologist

Mammograms

Fail to diagnose

QA sampling of reads shows other failures to identify suspicious breast masses

Detailed QA shows significant similar problems over entire 5 years of contract

principles
Principles

Patient Safety/Damage Control

Risk Communications

Accountability

patient safety damage control
Patient Safety/Damage Control
  • Patient Safety always most important
    • Involved patients
    • Recurrence
    • Look back
  • What happened?
    • Sentinel Event/Root Cause Analysis
    • QA investigations
    • Litigation reports
    • Criminal (NCIS/CID)
risk communications
Risk Communications
  • Think of the end first
  • Look Back letters
  • Congress/Chain of Command
    • QA
  • Public
  • Family
    • Healthcare Resolutions Program
    • BUMEDINST 6010.28
accountability
Accountability
  • Lessons learned
  • Retraining
  • Adverse privileging
  • NPDB
    • Paid torts (including Feres barred)
    • Final adverse actions
  • UCMJ/Relief for Cause
  • Civilian employee disciplinary action
  • Contracting Officer
case 11
Case #1
  • QA investigation
    • Joint RCA with Marines
  • QA review of provider performance
    • Reported to DPDB & PAR entry
  • Redesign of consult process
  • EHR
  • Congressional/CoC briefings - QA
  • Public Affairs engagement – No QA
case 21
Case #2
  • Multidrug toxicity
  • Sentinel Event/Root Cause Analysis
  • QA investigation
    • Forensic Pathologist
    • Lessons learned MC/NC/Pharmacy
    • Patch
    • KePRo
  • NCIS
  • Family
  • Local media
case 31
Case #3
  • Sentinel Event/ Root Cause Analysis
  • QA investigation
  • Litigation report
  • NCIS
    • AFIP found brain death
  • Adverse privileging
  • NPDB reports
  • Multiple lessons learned
case 41
Case #4
  • Tiger Team to re-read 3793 mammograms
    • Immediate look back letters all patients
    • Base media/Navy Times
  • Immediate contact for suspicious cases
    • Letters to all with normal results
  • Litigation report/FTCA claims
  • SECNAVDES
  • NPDB (adverse actions and paid tort)
  • Partnered with local media
navy update
Navy Update

BUMEDINST 4200.2C, Health Care Services Contracting, 3 June 2013

BUMEDINST 6230.16, Malaria Prevention and Control, 8 July 2013

BUMEDINST 6150.38A, Coding Program Business Practices, 10 July 2013

navy update1
Navy Update

BUMEDINST 5350.6, Use of Hand Held Alcohol Detection devices, 12 August 2013

BUMEDINST 6310.11A, Sexual Assault Prevention & Response Medical-Forensic Program, 2 May 2013

navy update2
Navy Update

BUMEDINST 6320.100, Chiropractic and licensed Acupuncture, 11 March 2013

ALNAV 040/13, Cancellation of SECNAVINST 6320.24A, Mental Health Evaluations of Members of the Armed Forces, 19 June 2013

questions
Questions

Jeff Sherman

Phone: (703) 681-8969

DSN: 761-8969

Jeff.Sherman@med.navy.mil

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