Nursing crew resource management: a follow-up report from the Veterans Health Administration.

Gary L. Sculli; Amanda M. Fore; Pricilla West; Julia Neily; Peter D. Mills; Douglas E. Paull

Commentary

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

March 13, 2013

Sculli GL, Fore AM, West P, et al. J Nurs Adm. 2013;43(3):122-6.

View more articles from the same authors.

This commentary describes an initiative that applied crew resource management techniques to nursing units in the Veterans Health Administration to improve care quality.

PubMed citation

Available at

Related Resources From the Same Author(s)

Improving patient safety and optimizing nursing teamwork using crew resource management techniques.

March 14, 2012

Retained guidewires in the Veterans Health Administration: getting to the root of the problem.

May 9, 2018

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project.

February 13, 2013

Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit.

November 6, 2013

A concept analysis of situational awareness in nursing.

April 17, 2013

Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training.

April 30, 2014

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

March 25, 2020

Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork.

August 12, 2015

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training.

November 18, 2009

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

August 18, 2010

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

April 29, 2015

Sharing lessons learned to prevent incorrect surgery.

November 21, 2012

Association between implementation of a medical team training program and surgical mortality.

October 20, 2010

Association between implementation of a medical team training program and surgical morbidity.

January 4, 2012

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.

October 24, 2018

Wrong-side thoracentesis: lessons learned from root cause analysis.

July 2, 2014

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned.

August 23, 2017

The effect of facility complexity on perceptions of safety climate in the operating room: size matters.

June 16, 2010

Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program.

September 14, 2011

The Daily Plan: including patients for safety's sake.

April 11, 2012

Using root cause analysis to reduce falls with injury in community settings.

August 1, 2012

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

August 21, 2013

Sharing lessons learned to prevent adverse events in anesthesiology nationwide.

August 21, 2019

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement.

June 1, 2022

Improving the bar-coded medication administration system at the Department of Veterans Affairs.

August 9, 2006

Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change.

June 8, 2016

The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities.

December 6, 2017

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.

May 28, 2014

Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration.

March 15, 2006

Medical team training: applying crew resource management in the Veterans Health Administration.

May 30, 2007

How well do incident reporting systems work on inpatient psychiatric units?

September 5, 2018

Awareness and use of a cognitive aid for anesthesiology.

September 19, 2007

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.

November 4, 2020

Curriculum development and implementation of a national interprofessional fellowship in patient safety.

September 5, 2018

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.

September 1, 2010

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.

December 8, 2010

Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system.

February 20, 2008

Institutional disclosure: promise and problems.

April 16, 2014

Incorrect surgical procedures within and outside of the operating room.

November 25, 2009

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

July 27, 2011

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

October 18, 2023

Effects of weekend admission and hospital teaching status on in-hospital mortality.

March 6, 2005

Using root cause analysis to reduce falls with injury in the psychiatric unit.

March 21, 2012

Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.

September 23, 2020

Pharmacy clarification of prescriptions ordered in primary care: a report from the Applied Strategies for Improving Patient Safety (ASIPS) collaborative.

February 8, 2006

Suicide attempts and completions on medical-surgical and intensive care units.

January 29, 2014

Suicide and suicide attempts on hospital grounds and clinic areas.

August 11, 2021

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

May 3, 2023

The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration.

April 22, 2020

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

May 24, 2023

Inpatient suicide and suicide attempts in Veterans Affairs hospitals.

August 20, 2008

Communication failures contributing to patient injury in anaesthesia malpractice claims.

September 1, 2021

Improving RCA performance: the Cornerstone Award and the power of positive reinforcement.

August 17, 2011

A paradigm shift to balance safety and quality in pediatric pain management.

March 6, 2013

Review of alternatives to root cause analysis: developing a robust system for incident report analysis.

September 18, 2019

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

November 17, 2021

A multihospital safety improvement effort and the dissemination of new knowledge.

March 6, 2005

A call to excellence.

March 6, 2005

Noise levels in Johns Hopkins Hospital.

December 21, 2005

Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards.

June 19, 2013

An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.

November 14, 2018

Root cause analysis of ICU adverse events in the Veterans Health Administration.

August 30, 2017

Early warning systems: the next level of rapid response.

January 25, 2012

Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.

July 22, 2009

The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations.

August 30, 2023

Systemic vulnerabilities to suicide among veterans from the Iraq and Afghanistan conflicts: review of case reports from a national Veterans Affairs database.

April 20, 2011

A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals.

February 17, 2010

Where should patient safety be installed?

November 29, 2017

Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: a panel study.

November 28, 2018

Defining optimal length of opioid pain medication prescription after common surgical procedures.

October 18, 2017

Comparison of medication safety systems in critical access hospitals: combined analysis of two studies.

September 21, 2016

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

November 24, 2021

Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).

December 3, 2014

The 80-hour duty week: rationale, early attitudes, and future questions.

September 20, 2006

Organizational costs of preventable medical errors.

March 6, 2005

Infections and interaction rituals in the organisation: clinician accounts of speaking up or remaining silent in the face of threats to patient safety.

December 16, 2015

Seeing risk and allocating responsibility: talk of culture and its consequences on the work of patient safety.

December 10, 2014

Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.

June 21, 2017

Effect of US Drug Enforcement Administration's rescheduling of hydrocodone combination analgesic products on opioid analgesic prescribing.

November 23, 2016

Association of resident fatigue and distress with perceived medical errors.

September 30, 2009

Building and sustaining a systemwide culture of safety.

December 14, 2005

Surgical never events in the United States.

January 9, 2013

Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States.

July 16, 2008

Readiness of US general surgery residents for independent practice.

October 4, 2017

Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis.

July 15, 2015

Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm reduction.

November 17, 2010

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.

June 2, 2021

Comparison of medication safety effectiveness among nine critical access hospitals.

January 8, 2014

Adverse patient safety events during the COVID epidemic.

May 17, 2023

Towards a more patient-centered approach to medication safety.

December 13, 2017

Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction.

January 25, 2023

Addressing physician burnout: the way forward.

February 22, 2017

Development of the barriers to error disclosure assessment tool.

September 27, 2017

The health care cost of drug-related morbidity and mortality in nursing facilities.

March 6, 2005

Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

March 27, 2005

Improving reporting of outpatient pediatric medical errors.

January 30, 2005

Related Resources

Interview

In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

October 31, 2023

Perspectives on Safety

Addressing Workplace Violence and Creating a Safer Workplace

October 31, 2023

Interview

In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing

August 30, 2023

Perspectives on Safety

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

August 30, 2023

Patient falls while under supervision: trends from incident reporting.

July 5, 2023

VHA's movement for change: implementing high-reliability principles and practices.

May 31, 2023

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

Annual Perspective

Annual Perspective: Psychological Safety of Healthcare Staff

March 31, 2022

Start the year off right by addressing these top 10 medication safety concerns from 2021.

February 9, 2022

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis.

February 3, 2021

Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem.

March 6, 2019

Decreasing surgical site infections by developing a high reliability culture.

February 6, 2019

Nurses' and patients' appraisals show patient safety in hospitals remains a concern.

November 21, 2018

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.

October 24, 2018

Cost–benefit analysis of a support program for nursing staff.

May 24, 2017

Health care worker fatigue.

September 21, 2016

Addressing nurse fatigue to promote safety and health: joint responsibilities of registered nurses and employers to reduce risks.

September 14, 2016

Using Kotter's change model for implementing bedside handoff: a quality improvement project.

August 24, 2016

High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality.

May 25, 2016

Creating a nurse-led culture to minimize horizontal violence in the acute care setting: a multi-interventional approach.

May 11, 2016

Quality and patient safety teams in the perioperative setting.

January 6, 2016

Accountability in nursing practice: why it is important for patient safety.

December 10, 2014

Multidisciplinary in-hospital teams improve patient outcomes: a review.

October 22, 2014

Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy.

August 27, 2014

The influence of organizational factors on patient safety: examining successful handoffs in health care.

August 27, 2014

Patient involvement in patient safety: a qualitative study of nursing staff and patient perceptions.

August 13, 2014

Nearing zero...reducing grade C medication errors.

July 23, 2014

Weaving a healthcare tapestry of safety and communication.

July 16, 2014

Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes.

July 9, 2014

The quest for safe surgical care: are we missing the obvious?

April 23, 2014

See More About The Topic

Hospitals

Nurses

Health Care Executives and Administrators

Organizational Behaviorists

Nurse Care

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site