U.S. Department of Health & Human Services
Patient Safety Primers
What are Patient Safety Primers?
Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. Communication barriers across hierarchies, failure to acknowledge human fallibility, and lack of
combine to cause poor teamwork, which can lead to clinical adverse events.
has long recognized that safety requires crew members to receive specific training in working as a team, in addition to technical training. Several studies have documented poor levels of teamwork in medicine. A classic
that compared perceptions of teamwork between operating room personnel and flight crews found that attending surgeons were significantly less likely to acknowledge fatigue or accept suggestions from junior staff than were pilots.
Growing recognition of the need for teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings. While there is no single standardized teamwork training program for health care, all programs stress several key concepts. Teamwork training attempts to minimize the potential for error by training each team member to respond appropriately in acute situations. Teamwork training thus focuses on developing effective communication skills and a more cohesive environment among team members, and on creating an atmosphere in which all personnel feel comfortable speaking up when they suspect a problem. Team members are trained to cross-check each other's actions, offer assistance when needed, and address errors in a nonjudgmental fashion.
and providing feedback, especially after
, are essential components of teamwork training.
Teamwork training also emphasizes the role of
—for example, the effects of fatigue, expected or predictable perceptual errors (such as misreading monitors or mishearing instructions), and the impact of different management styles and organizational cultures. Teamwork training may be purely
or accompanied by
of specific scenarios such as cardiopulmonary resuscitation, "crash" Caesarean section, or multiorgan trauma.
Teamwork training programs—implementation and effectiveness
Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS) program was developed in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. TeamSTEPPS has been successfully implemented in a variety of clinical settings, including
intensive care units
. AHRQ offers a comprehensive curriculum and training program for interested organizations, which includes hands-on training through regular meetings and conferences as well as an
with an implementation guide, training materials, and
. Although originally developed for hospitals, the TeamSTEPPS program has been expanded to include
. Other examples of teamwork training programs include the Veterans Affairs
Medical Team Training program
crew resource management
(which is based on aviation industry teamwork programs).
Teamwork training programs have been implemented in a wide variety of clinical environments, including the emergency department, operating rooms,
, and outpatient primary care clinics. They are also being used to train hospital
in responding to safety events. The evidence supporting the benefits of such programs in health care is growing. A landmark
conducted in the Veterans Affairs hospital system demonstrated a significant reduction in surgical mortality associated with implementation of the Medical Team Training program. Other
have consistently demonstrated improvements in participants' knowledge of teamwork principles, attitudes toward the importance of teamwork, and overall safety climate, although these have
translated into durable behavioral changes or enhanced skills. The effectiveness of teamwork training may depend on baseline perceptions of
and readiness for change within a given unit or organization, as well as the intensity and duration of the intervention.
All military health facilities participate in the TeamSTEPPS program, and the Medical Team Training program is being widely implemented in Veterans Affairs facilities. However, teamwork training is not required for other health care facilities. The Joint Commission's
for preventing wrong-site surgery mandates a preoperative "time out," based on teamwork training principles, in which all team members review the details of the surgery to take place. Many organizations are now coupling teamwork training programs with more specific efforts to structure communication, such as
(situation, background, assessment, recommendation) training. Successful organizational approaches to improving safety, such as the
Comprehensive Unit-Based Safety Program
, also explicitly incorporate teamwork training principles.
What's New in Teamwork Training on AHRQ PSNet
Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval.
Stawicki SP, Cook CH, Anderson HL III, et al; OPUS 12 Foundation Multicenter Trials Group. Am J Surg. 2014;208:65-72.
A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and application?
Dietz AS, Pronovost PJ, Benson KN, et al. BMJ Qual Saf. 2014 Aug 25; [Epub ahead of print].
View all AHRQ PSNet resources on Teamwork Training
Editor's Picks for Teamwork Training
The Inside of a Time Out
David L. Feldman, MD, MBA. AHRQ WebM&M [serial online]. May 2008
Team Training: Classroom Training vs. High-Fidelity Simulation
Stephen D. Pratt, MD and Benjamin P. Sachs, MB. AHRQ WebM&M [serial online]. March 2006
What Does Simulation Add to Teamwork Training?
David M. Gaba, MD. AHRQ WebM&M [serial online]. March 2006
Aviation Safety Methods: Quickly Adopted but Questions Remain
Eric J. Thomas, MD, MPH. AHRQ WebM&M [serial online]. January 2006
In Conversation with…Jack Barker, PhD
AHRQ WebM&M [serial online]. January 2006
Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.
Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2012;22:118-126.
Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.
Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.
Association between implementation of a medical team training program and surgical mortality.
Neily J, Mills PD, Young-Xu Y, et al. JAMA
Surgical team behaviors and patient outcomes.
Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.
Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.
Nielsen PE, Goldman MB, Mann S, et al. Obstet Gynecol. 2007;109:48-55.
Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.
Morey JC, Simon R, Jay GD, et al. Health Serv Res. 2002;37:1553-1581.
Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.
TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety.
Washington, DC: Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
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Last Updated: July 2014
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Agency for Healthcare Research and Quality
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University of California, San Francisco
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