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RISK COMMUNICATIONS & NAVY UPDATE

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

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  1. RISK COMMUNICATIONS & NAVY UPDATE Jeff Sherman Director, Medical-Legal Affairs BUMED

  2. 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

  3. 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

  4. 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

  5. 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

  6. WHAT DO YOU DO?

  7. Principles Patient Safety/Damage Control Risk Communications Accountability

  8. 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)

  9. Risk Communications • Think of the end first • Look Back letters • Congress/Chain of Command • QA • Public • Family • Healthcare Resolutions Program • BUMEDINST 6010.28

  10. 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

  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

  12. Case #2 • Multidrug toxicity • Sentinel Event/Root Cause Analysis • QA investigation • Forensic Pathologist • Lessons learned MC/NC/Pharmacy • Patch • KePRo • NCIS • Family • Local media

  13. Case #3 • Sentinel Event/ Root Cause Analysis • QA investigation • Litigation report • NCIS • AFIP found brain death • Adverse privileging • NPDB reports • Multiple lessons learned

  14. 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

  15. 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

  16. 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

  17. 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

  18. Questions Jeff Sherman Phone: (703) 681-8969 DSN: 761-8969 Jeff.Sherman@med.navy.mil

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