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Teamwork Training
See Primer. Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The need for improved teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings.

Time Outs
Time outs refer to planned periods of quiet and/or interdisciplinary discussion focused on ensuring that key procedural details have been addressed. For instance, protocols for ensuring correct site surgery often recommend a time out to confirm the identification of the patient, the surgical procedure, site, and other key aspects, often stating them aloud for double-checking by other team members. In addition to avoiding major misidentification errors involving the patient or surgical site, such a time out ensures that all team members share the same "game plan," so to speak. Taking the time to focus on listening and communicating the plans as a team can rectify miscommunications and misunderstandings before a procedure gets underway.

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Signals for detecting likely adverse events. Triggers alert providers involved in patient safety activities to probable adverse events so they can review the medical record to determine if an actual or potential adverse event has occurred. For instance, if a hospitalized patient received naloxone (a drug used to reverse the effects of narcotics), the patient probably received an excessive dose of morphine or some other opiate. In the emergency department, the use of naloxone would more likely represent treatment of a self-inflected opiate overdose, so the trigger would have little value in that setting. But, among patients already admitted to hospital, a pharmacy could use the administration of naloxone as a "trigger" to investigate possible adverse drug events.

In cases in which the trigger correctly identified an adverse event, causative factors can be identified and, over time, interventions developed to reduce the frequency of particularly common causes of adverse events. The traditional use of triggers has been to efficiently identify adverse events after the fact. However, using triggers in real time has tremendous potential as a patient safety tool. In a study of real-time triggers in a single community hospital, for example, more than 1000 triggers were generated in 6 months, and approximately 25% led to physician action and would not have been recognized without the trigger.

As with any alert or alarm system, the threshold for generating triggers has to balance true and false positives. The system will lose its value if too many triggers prove to be false alarms. This concern is less relevant when triggers are used as chart review tools. In such cases, the tolerance of false alarms depends only on the availability of sufficient resources for medical record review. Reviewing four false alarms for every true adverse event might be quite reasonable in the context of an institutional safety program, but frontline providers would balk at (and eventually ignore) a trigger system that generated four false alarms for every true one.

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