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

2. World-Class Care…Anytime, Anywhere 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 2

3. World-Class Care…Anytime, Anywhere 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 3

4. World-Class Care…Anytime, Anywhere 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 4

5. World-Class Care…Anytime, Anywhere 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 5

6. World-Class Care…Anytime, Anywhere WHAT DO YOU DO? 6

7. World-Class Care…Anytime, Anywhere Principles Patient Safety/Damage Control Risk Communications Accountability 7

8. World-Class Care…Anytime, Anywhere 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) 8

9. World-Class Care…Anytime, Anywhere Risk Communications Think of the end first Look Back letters Congress/Chain of Command – QA Public Family – Healthcare Resolutions Program – BUMEDINST 6010.28 9

10. World-Class Care…Anytime, Anywhere 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 10

11. World-Class Care…Anytime, Anywhere 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 11

12. World-Class Care…Anytime, Anywhere Case #2 Multidrug toxicity Sentinel Event/Root Cause Analysis QA investigation – Forensic Pathologist – Lessons learned MC/NC/Pharmacy – Patch – KePRo NCIS Family Local media 12

13. World-Class Care…Anytime, Anywhere Case #3 Sentinel Event/ Root Cause Analysis QA investigation Litigation report NCIS – AFIP found brain death Adverse privileging NPDB reports Multiple lessons learned 13

14. World-Class Care…Anytime, Anywhere 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 14

15. World-Class Care…Anytime, Anywhere 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 15

16. World-Class Care…Anytime, Anywhere 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 16

17. World-Class Care…Anytime, Anywhere 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 17

18. World-Class Care…Anytime, Anywhere Questions Jeff Sherman Phone: (703) 681-8969 DSN: 761-8969 Jeff.Sherman@med.navy.mil 18